Vascular Examination

Ashley Southall Sept 2005

Overview

Quick anatomy

Quick pathology

Scheme for examining peripheral vascular system

Anatomy

Arterial and venous systems

Arterial anatomy

AortaCommon iliacsExternal iliacsCommon femoralSuperficial femoral

PoplitealAnterior and Posterior TibialsPeronealDorsalis pedis

Pathology

Atheroma and occlusion

Aneurysms

Skin changes e.g. ulcers, gangrene

Examination

Necessary equipmentIntroduce yourselfPrivacyPositionLightExpose

Examination

NIPPLE

Examination

Necessary equipmentIntroduce yourselfPrivacyPositionLightExpose

Examination

Full cardiovascular exam

Claudicants 20% 5yr mortality

Assess fitness for surgery

In exam tell this to examiner at end

Inspection

Look around the bedside for cluesTablets/ inhalers/ spraysOxygenHeparin pumpsArtificial limbsInsulin pumps/ syringesCigarettes!

Inspection

Inspect the patient as a whole

In pain?

General appearance

Inspection

Hands

Nicotine staining of fingers

Amputations

Inspection

Abdomen / groins

Obvious pulsatile mass (AAA)ScarsAAA repairFem-pop bypass

Inspection

Legs

ScarsPallorVenous gutteringDiscolorationUlcers

Inspection

Pressure areas

MalleoliHeelBall of footHead of 5th metatarsalTips of the toesBetween toes

Palpation

Temperature (back of hand)

Capillary refill

Pulses

Palpation

Pulses

FemoralPoplitealDorsalis pedisPosterior tibial

Palpation

Femoral pulse

Landmark – mid-inguinal point

Palpation

Popliteal pulse

Place thumbs on tibial tuberosity

Press fingers firmly into lower part of popliteal fossa

Palpation

Dorsalis pedis

Starts midway between the malleoli anteriorly (continuation of ant. tibial)

Runs to cleft between first and second metatarsal bones

Palpation

Posterior tibial

Behind the medial malleolus

Palpation

Test muscle power and sensation

Palpate for AAA

Auscultation

Listen for bruits

Abdominal aortaRenal arteriesIliacs / femoralsAdductor canal (2/3 down antero-medial thigh)

Other

Buerger’s angle

Support the patient’s heelAsk pt to raise leg to 90°Should stay pink to 90°Foot pale at 50° = severe ischaemiaFoot pale at 25° = critical ischaemia

Other

Swing legs over edge of bed

If legs go engorged and purple, Buerger’s test = positive

ABPIs

Ankle Brachial Pressure Index

Take BP in both arms with Doppler US probeTake BP with cuff around lower leg using a Doppler US probe(highest cuff pressure at which pulse can be heard)Leg BP/ Arm BP = ABPI

ABPI

Clinical status ABPI

Symptom free 1 or moreIntermittent claudication 0.95 - 0.5Rest pain 0.5 - 0.3Gangrene and ulceration <0.2

Venous Exam

Lower limb venous anatomy

Superficial and deep systemsLong and short saphenous systemsPerforators with valvesDeep system within leg muscles

Inspection

Expose patient (both legs visible to groin)

Stand patient up

Inspect the leg

InspectionLook for

Varicose veinsVenulectasias (small venous stars)Haemosiderin depositsLipodermatosclerosisUlcersVenous eczemaScars – previous ulcers, surgeryThrombophlebitis

Palpation

Palpate varicositiesPalpate saphenofemoral junctionLocate femoral arteryMid-inguinal point halfway between ASIS and pubic symphysisFemoral vein lies approx 1cm medial to this (NAVY)

Palpation

Saphenofemoral junction lies approx 2cm below this.

Keep one hand on saphenofemoral junctionTap varicosityIf saphenofemoral junction is incompetent, thrill may be felt

Palpation

Doppler test

Place probe over SFJCompress varicosityWhoosh heard as vein compressesIf incompetent long whoosh heard when released

Palpation

Can also do this for sapheno-popliteal junction

Palpation

Trendelenberg test

Lie patient downRaise leg to empty varicositiesApply pressure to SFJ to occlude itMaintain the pressure while getting the pt to standIf varicosities do not refill, saphenofemoral incompetence is present

Palpation

Tourniquet test

As for TrendelenbergApply tourniquet to upper thighStand patient upIf varicosities fill, level of incompetence is below the tourniquet

Palpation

Repeat the test with the tourniquet at different levels

Level of incompetence between lowest tourniquet level at which veins still filled and level of tourniquet when veins controlled

Further tests

Full abdominal exam

Arterial exam

Duplex ultrasound scanning

Thank you