Peripheral Vascular Exam Notes

Peripheral vs. Central Vessels

  • Central Vessels:
    • Located centrally in the body.
    • Examples: heart, aorta, superior and inferior vena cava.
  • Peripheral Vessels:
    • Located further away from the heart (extremities - arms and legs).
    • Peripheral Vascular Exam: focuses on arteries, veins, lymph tissues, and lymph nodes in the extremities.
  • Vascular:
    • Encompasses arteries, veins, and lymphatics.

Anatomy Review & Cardiac Cycle

  • Arteries respond to variations in the cardiac cycle (squeeze and relaxation).
  • Changes centrally in heart pumping can be observed peripherally in arteries.
  • Artery Size:
    • Arteries closer to the heart are wider.
    • Arteries in the fingertips are narrower.
    • This impacts procedures and locating arteries.
  • Main Arteries of the Arm:
    • Brachial, Radial, and Ulnar.
    • Radial is the most commonly assessed.

Radial Pulse Palpation

  • Anatomical Position:
    • Palms facing forward (ventral surface).
  • Procedure:
    • Use index and middle fingers.
    • Locate the flexor surface (ventral surface) on the lateral portion of the wrist.
    • Apply varying pressure (too hard or too soft).
    • Flex the wrist slightly.
    • Move laterally to medially to find the pulse.

Brachial Pulse

  • Situations for Assessment:
    • Cold situations, unsure of pulse presence.
    • Ankle-Brachial Index (ABI).
    • Carotid pulse typically preferred (central).
  • Ulnar Pulse: Not commonly palpated.

Lower Extremity Pulses

  • Femoral Pulse:
    • Located below the inguinal ligament.
    • Used in code scenarios to assess pulse.
  • Popliteal Pulse:
    • Located behind the kneecap.
    • Commonly checked by orthopedic and vascular surgeons.
    • Runs deeply and medially behind the femur, often difficult to palpate.
  • Artery Depth:
    • Pulses closer to the heart are deeper.
    • Brachial artery is deeper than the radial artery.
    • Popliteal pulse is deeper than dorsalis pedis and posterior tibialis pulses.
  • Dorsalis Pedis Pulse:
    • Most commonly checked pulse in the lower extremity.
    • Located on the dorsum of the foot (midfoot, tarsal bones).
    • Lateral to the extensor tendon of the big toe.

Veins

  • Thin walls, distendable.
  • Deep Veins:
    • Carry venous return to the heart for reoxygenation.
  • Superficial Veins:
    • Great Saphenous Vein: harvested for coronary artery bypass grafts (CABG).
  • CABG Procedure:
    • Surgeons harvest the great saphenous vein from the leg, dissecting fat away from the vein.
    • The harvested vein is used as a bypass graft on the patient’s heart.
  • One-Way Valves:
    • Prevent blood pooling, unless there's a problem.

Lymph System

  • Lymph Node Characteristics:
    • Round, oval, or bean-shaped.
    • Mobile (able to be moved around).
  • Fixed or matted lymph nodes are indicative of disease.

Peripheral Vascular Symptoms: Review of Systems

  • Symptoms to ask about for chest pain, extremity complaints or during annual physicals:
    • Pain in the arms.
      • Possible Diagnoses: Myocardial Infarction (MI), Deep Vein Thrombosis (DVT), Carpal Tunnel Syndrome, Peripheral Arterial Disease (PAD), Diabetic Neuropathy.
      • MI: Arterial
      • DVT: Venous
      • PAD: Plaque/thrombus buildup in peripheral artery walls.
    • Intermittent Claudication: Pain in the calf with exertion, relieved by rest.
      • Underlying Disease: Peripheral Arterial Disease (PAD).
      • Analogy: Chest pain (angina) in the calf; stress test for the legs.
      • Mechanism: Reduced blood flow due to plaque/thrombus.
      • Hyperlipidemia/cholesterol buildup in arteries increases risk.
      • Arterial Spasm: Raynaud's.
    • Cool Extremities, Numbness, Pale Color, Hair Loss: Indicate decreased blood flow.
    • Swelling in Calves, Legs, or Feet.
      • Associated Diseases: DVT, Congestive Heart Failure (CHF).
    • Color Changes, Swelling and Redness

Claudication

  • Important Question: "Have you ever had any pain or cramping in the legs when walking or with exercise? Does the pain get better when you rest?"

PAD Symptoms

  • Most patients are asymptomatic or have nonspecific symptoms.
  • Nonspecific Symptoms: Vague, general complaints. (e.g., legs feel tired or weak).
  • Only 10% of PAD patients experience intermittent claudication.
  • Aggressive risk factor intervention and screening for subclinical PAD are crucial.
  • Subclinical: No obvious symptoms or physical exam findings, yet the disease exists.

Ankle Brachial Index (ABI)

  • Test to detect stenosis in the extremities.
  • Detects stenosis of 50% or more in major vessels of the legs.
  • Procedure: Measure systolic blood pressure in each arm and pedal pulse using Doppler ultrasonography.
  • Calculation: Divide arm pressure by ankle pressure.
  • Interpretation: Results indicate mild to moderate or severe disease.
  • Limitation: May not be accurate if the vessel is less than 50% occluded.

Peripheral Vascular Exam

  • Inspection and Palpation of Arms and Legs.
  • Both Arms and Legs:
    • Size: Check for equality.
    • Symmetry: Compare each side.
    • Skin Color: Note any blue or white discoloration.
  • Arms:
    • Palpate Radial Pulse.
    • Palpate Lymph Nodes (if indicated).
  • Legs:
    • Palpate Dorsalis Pedis Pulse.
    • Check for Peripheral Edema.

Radial and Brachial Pulse Palpation

  • Radial Pulse: already discussed.
  • Brachial Pulse:
    • Use: Orthopedic or vascular assessment of blood flow.
    • Technique: Flex elbow, place fingers in antecubital crease.
    • Note: Brachial artery runs deeply; absence of palpable pulse is not always abnormal.
    • Assess distal arm: check for pinkness, perfusion, and capillary refill.
  • Lymph Nodes: Palpate for round, mobile nodes; absence is not always abnormal.

Leg Exam

  • Remove shoes and socks.
  • Assess skin color, venous stasis ulcers, blood flow, and palpate pulses.
  • Check for:
    • Size, Symmetry, Swelling, Venous Patterns, Rashes

Grading of Pulses

  • Two Plus (+2): Normal, brisk amplitude.
  • One Plus (+1): Diminished amplitude.
  • Three Plus (+3): Strong, hammering, may indicate tachycardia.
  • Zero (0): Absent.

Edema

  • Assess for pitting edema.

  • Compare one side to the other.

  • Press firmly over the dorsum of each foot for 5 seconds, then release.

  • Pitting Edema: Thumb imprint remains.

  • Palpate behind the medial malleolus and shins to assess the extent of edema.

  • CHF Exacerbation: Pitting edema improves distally as fluid is diuresed off.

  • Edema Progression/Resolution: dorsum of the foot --> medial malleolus --> shins.

  • Analogy: Bucket of water filling from bottom to top (exacerbation) and emptying from top to bottom (resolution).

  • Causes:

    • DVT usually presents with nonpitting edema, swelling is evenly spread.
    • CHF typically presents with pitting edema.