Peripheral arterial examination

You may be asked to focus on the lower limbs – if so, do this after general inspection.

Introduction

• Wash hands
• Introduce self
• Ask Patient’s name, DOB and what they like to be called
• Explain examination and obtain consent
• Lie the patient flat and expose legs

General inspection

• Look at the patient in general
  • Do they look well/unwell?
  • Are they in pain/discomfort?
  • Note any amputations
• Consider risk factors for vascular disease, for example age and body habitus
• Look around the bed, you may see things such as:
  • Oxygen
  • Mobility aids
  • Medications (e.g. insulin)
  • Cigarettes
  • Capillary glucose monitor

Upper limbs

• Inspection, look for: skin colour changes (pink, pale, mottled), ischaemic changes (e.g. gangrene), tar-stained fingers, tendon xanthomata, capillary glucose testing marks
• Palpation:
  • Temperature – feel the temperature with the back of your hand (cool = reduced peripheral perfusion)
  • Capillary refill – press down for 5 seconds with your fingertip and count how long it takes to reperfuse (should be <2 seconds)
  • Pulses
    • Radial pulse
    • Radio-radial delay (aortic dissection/aneurysm or proximal coarctation)
    • Offer to test for radio-femoral delay (aortic coarctation); brachial pulse; and blood pressure in both arms (>10mmHg difference = significant and suggests aortic dissection, proximal coarctation or subclavian artery stenosis)

Face

• Eyes: look at the eyes for corneal arcus and xanthelasma (hyperlipidaemia)
• Mouth: look under the tongue for central cyanosis
• Carotid pulse: feel the character and auscultate for bruits (carotid artery stenosis)

Abdomen

• Inspection: body habitus, scars, visible aortic pulsation
• Aortic and femoral pulses: palpate pulses, auscultate for bruits (‘machinery’ aortic bruit = AAA)

Lower limbs (main part)

Check for pain in legs. Examine with patient standing and then lying supine.

Inspection (especially feet)

• Skin colour changes (pink, pale, mottled)
• Ischaemic changes: especially between toes and heels – don’t miss toe amputations!
• Trophic changes (shiny skin, hair loss, thin skin, ulcers)
• Muscle wasting
• Pedal oedema
• Scars – ensure you also expose the femoral region (e.g. bypass operations, venous grafting)

Trophic changes with bilateral callous formation and early ulceration

CABG vein grafting scar

Peripheral oedema

Palpation

• Temperature: feel along length of leg (cool = reduced peripheral perfusion)
• Capillary refill (should be <2 seconds)
• Pulses: feel pulses starting proximally (femoral, popliteal, posterior tibial, dorsalis pedis); squeeze calves (tenderness may suggest critical ischaemia or DVT); check peripheral sensation

Examine for Buerger’s angle

To complete

• Thank patient and restore clothing
• ‘To complete my examination, I would perform a full cardiovascular examination, test sensation, and use Doppler ultrasound to further assess pulses.’
• Summarise and suggest further investigations you would consider after a full history (e.g. ABPI, duplex USS, MR or CT angiography, catheter angiography, bloods, ulcer swabs, ECG, HbA1C etc.)

Types of artery bypass grafts

Axillofemoral

Femorofemoral

Iliofemoral

Iliofemoral

Femoropopliteal

Aortobifemoral

Details

• Aorta to both femoral arteries (open operation)

Indications

• Aortoiliac occlusive disease
• Axillofemoral used for patients who are unable to tolerate aortobifemoral (often elderly patients or patients with significant comorbidities)

Sites on examination

• Midline laparotomy scar
• Bilateral groin scars

Axillofemoral / Axillobifemoral

Details

• Axillary artery to one/both femoral arteries
• (graft tunnelled subcutaneously)

Indications

• Aortoiliac occlusive disease
• Axillofemoral used for patients who are unable to tolerate aortobifemoral (often elderly patients or patients with significant comorbidities)

Sites on examination

• Axillary scar
• Unilateral/bilateral groin scars
• Graft may be palpable

Femorofemoral

Detials

• Femoral artery to femoral artery
• (graft tunnelled subcutaneously or in pre-peritoneal space)

Indications

• Unilateral iliac disease

Sites on examination

• Bilateral groin scars
• Graft may be palpable

Iliofemoral

Details

• Iliac artery to femoral artery
• (iliac artery on ipsilateral or contralateral side may be used)

Indications

• Unilateral iliac disease

Sites on examination

• Two groin scars (may be on the same or opposite sides depending on operation)

Femoropopliteal / Femorotibial / Femorodistal

Details

• Femoral artery to popliteal artery, a tibial artery or distally
• (graft may be tunnelled subcutaneously or anatomically)

Indications

• Femoropopliteal disease

Sites on examination

• Groin scar
• Medial lower leg scar
• Graft may be palpable

Why don’t you test your knowledge?

What investigations and imaging would you consider to investigate peripheral arterial disease?

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What are the advantages / disadvantages of MRA and catheter angiography?

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How is peripheral arterial disease managed?

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Now try a practice OSCE station or two

1. Try a peripheral arterial examination
2. You should also be comfortable taking a claudication history
3. There’s lots more stations here

Picture references

Pitting oedema: James Heilman, licensed under the Creative Commons Attribution-Share Alike 3.0 Unported license (https://creativecommons.org/licenses/by-sa/3.0/deed.en). Sourced from: https://en.m.wikipedia.org/wiki/File:Combinpedal.jpg