Peripheral arterial system – Clinical Examination

 

Peripheral arterial system

Inspection

Color changes

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Trophic changes and Tissue loss (Ulcer / Gangrene)and tissue loss

    1. Pressure areas and between toes (Ischemic ulceration – Gangrene)
    2. Skin and appendages (Temperature – Loss of hair – Loss of sebaceous and sweat glands – Dry skin – Deformed and brittle nails – Loss of nail luster – Xanthelesmata and xanthomata)
    3. Subcutaneous tissues (Loss of subcutaneous fat – Thin skin – Tapered toes)
    4. Venous guttering
    5. Muscles and tendons (Wasted muscle)
    6. Bones and joints (Osteoporosis)
Vascular angle (Buerger’s Angle)

Palpation

  1. Temperature (and tenderness)
  2. Capillary refill
  3. Peripheral pulses

Complete 

Critical Limb Ischemia = Rest Pain or Tissue Loss (Ulcer / Gangrene)

Taking history from a patient with an ischemic limb

Follow the general scheme (on this page)  and use the following set of symptoms in the part of “Other symptoms in Relation to the main complaint

  • Pain

Intermittent claudicating

Rest pain

Site Site Foot and toes
Distal arterial disease Foot
Superficial femoral artery calf
Aortoiliac disease
  • Gluteal region
  • Thigh
  • calf
Onset insidiously Onset
Course Course
Duration Duration
Severity Claudication distance Severity Patients spend the night sitting in chair in attempt to relieve pain
Character Cramp-like Character Continuous aching
Radiation Radiation
Referral Referral
Relieving factors Rest Relieving factors Strong analgesics
Exacerbating factors Exercise Exacerbating factors
  • Night
  • Elevation of the leg
  • Warmth
Relation to other symptoms Relation to other symptoms Tissue loss
Cause Muscular ischemia Cause Nerve ischemia
  • Tissue changes and loss
    • Trophic changes (Loss of skin appendages – Loss of subcutaneous fat – Muscle wasting – Bone osteoporotic)
    • Ulceration or Gangrene
  • Symptoms of atherosclerosis elsewhere
    • Brain (TIAs – Stroke)
    • Heart (Angina pectoris – MI)
    • Kidney (Hypertension – Haematuria)
    • Intestine (Postprandial angina)
  • Possible cause
    • Predisposing factors of atherosclerosis
      • Cigarette smoking – Hyperlipidaemia – Hypertension – Diabetes mellitus – Obesity – Physical inactivity – Diet high in saturated fats – Hyperhomocysteinaemia – Raised Lp(a) lipoprotein concentrations – Hypercoagulable states
    • Factors suggesting Burger’s disease
      • Male – Between 20-40 years – No risk factors of atherosclerosis – Smoking

Differential diagnosis of chronic lower limb ischemia

Atherosclerosis

Buerger’s disease

Age of onset Elderly 20-40 years
Sex Commoner in males Exclusively in males
Aetiology
  • Hypertension
  • Hypercholesterolaemia
  • Smoking
  • Diabetes mellitus
  • Hypertiglyceridemia
  • Obesity
  • Sedentary or stressful lifestyle
  • Positive family history
Smoking
Level of lesion
  • Aortoiliac
  • Femoro-popliteal
  • Distal
  • Distal vessels
  • Patchy distribution
Pathology Mainly intimal ‘atheroma’
  • Inflamed neurovascular bundle
  • Thrombi that block lumen
Migrating thrombophlebitis Absent Usually present
Rest pain May be present but late Marked early feature

Differentiation of embolus and acute arterial thrombosis (thrombosis in situ)

Embolus

Thrombosis

Severity Complete (no collaterals) Incomplete (collaterals)
Onset Seconds or minutes Hours or days
Limb affected Leg 3:1 arm Leg 10:1 arm
Multiple sites Up to 15% Rare
Embolic source Present (usually atrial fibrillation) Absent
Previous claudication Absent Present
Palpation of artery Soft, tender Hard, calcified
Bruits Absent Present
Contralateral leg pulses Present Absent
Diagnosis Clinical Angiography
Treatment Embolectomy, warfarin Medical, bypass,

thrombolysis