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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:

  1. Temperature – feel the temperature with the back of your hand (cool = reduced peripheral perfusion)
  2. Capillary refill – press down for 5 seconds with your fingertip and count how long it takes to reperfuse (should be <2 seconds)
  3. 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

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

Abdomen

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

How to… Palpate the aorta

  • Press down with your finger tips (one hand each side) in the horizontal plane midway between the umbilicus and xiphoid process, starting laterally and moving medially
  • The ulnar borders of your hands should be parallel with the costal margins
  • A pulsatile mass, i.e. upward movement, can be normal
  • An expansile mass, i.e. outward movement, suggests AAA

Lower limbs (main part)

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

Inspection (especially feet)

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

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

How to… Examine for Buerger’s angle

  • Check for any pain in leg
  • With patient lying supine, lift their leg until heel becomes pale then hold for 30 seconds (if it does not become pale, test is normal; if it becomes pale, the degree of hip flexion is Buerger’s angle)
  • Now ask patient to sit up and hang their legs over the edge of the bed
  • Watch their feet for 2-3 minutes
  • Pallor followed by reactive hyperaemia (rubor) on dependency is a positive test and implies significant peripheral arterial disease

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.)

How to… Measure ABPI using Doppler

  • Measure the brachial SBP of both arms (place the Doppler probe at 45˚ over the brachial artery, inflate the cuff over the upper arm until the Doppler signal stops, then gradually deflate it – the SBP is the cuff pressure at which the Doppler signal returns)
  • Measure the ankle SBP of both legs (repeat the above procedure but with the cuff around the lower shin and the Doppler probe over the dorsalis pedis or posterior tibial artery)
  • Right ABPI = right ankle SBP / highest brachial SBP from either arm
  • Left ABPI = left ankle SBP / highest brachial SBP from either arm

Types of artery bypass grafts

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?

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
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