Peripheral vascular assessment notes

Preparation and overall approach

• Purpose: Peripheral vascular assessment as described in Jarvis et al. for adult physical examination.
• Sequence of examination:
  • Start with arms at the very beginning while the patient is sitting and checking vital signs.
  • Examine legs directly after the abdominal examination while the patient is still supine.
  • Have the patient stand up to evaluate leg veins.
• Anatomy and related chapters:
  • Peripheral vascular findings relate to skin (Chapter 22), musculoskeletal (Chapter 20), and neurological findings (Chapter 12).
• Methods:
  • Use inspection and palpation.
  • Compare findings with the opposite extremity (bilateral comparison).
• Equipment (as needed): hygiene solution, tape measure, tourniquet or blood pressure cuff, stethoscope, Doppler.
• Purpose of tests: detect abnormal peripheral vascular signs and guide further assessment (e.g., DVT suspicion, arterial insufficiency, lymphedema).

Examination mechanics: arms – inspection and palpation

• Begin with both hands:
  • Inspect color of skin and nailbeds; assess temperature, texture, and turgor of skin; look for lesions, edema, or clubbing.
  • Use profile sign (view the finger from the side) to detect early clubbing; normal nail bed angle is $160^ op^ ext{o}$.
• Capillary refill:
  • With hands near heart level, depress and blanch the nail beds; release and note color return time.
  • Normal refill: color returns in less than $2 ext{ s}$ (usually a fraction of a second).
  • Factors that can skew: cool room or low body temperature, cigarette smoking, peripheral edema, anemia.
• Symmetry and deformities:
  • The two arms should be similar in size.
  • Clubbing and flattening of the angle may indicate congenital cyanotic heart disease or cardiopulmonary disease.
• Upper extremity edema:
  • Edema of the upper extremities can occur when lymphatic drainage is obstructed (e.g., after breast surgery).

Examination mechanics: arms – pulses and arteries

• Palpate upper limb pulses:
  • Palpate bilateral radial pulses; assess rate, rhythm, elasticity of vessel wall, and equal force.
  • Grade pulse strength on a three-point scale: 3+ = increased, full, bounding; 2+ = normal; 1+ = weak; 0 = absent.
• Ulnar pulses:
  • Not usually necessary to palpate; if indicated, palpate along the medial side of the inner forearm; often not palpable in normal individuals.
• Brachial pulses:
  • Palpate brachial pulses; their strength should be equal bilaterally.
• Additional notes:
  • Needle tracks or small marks indicate past intravenous drug use; possible inflammation or infection; linear scars on wrists may indicate self-inflicted injury.
  • Pulse palpation can be more difficult in obese individuals.
  • Abnormal pulse findings:
  • Full, bounding pulse (3+) can occur with hyperkinetic states (exercise, anxiety, fever), anemia, hyperthyroidism.
  • Weak, thready pulse (1+) can occur with shock or peripheral arterial disease (PAD).
  • If a radial artery was used for a coronary artery bypass graft, the ulnar artery pulse is often examined to ensure collateral flow.

Examination mechanics: legs – inspection

• Keep genitalia draped; inspect both legs together for:
  • Skin color, hair distribution, venous pattern, size (swelling or atrophy), lesions, or ulcers.
• Hair distribution:
  • Normally leg hair covers the legs; hair on the dorsum of the toes may remain even when leg hair is shaved; hair distribution decreases with age.
• Skin signs:
  • Pallor with vasoconstriction; erythema with vasodilation; cyanosis.
• Malnutrition signs suggesting arterial insufficiency:
  • Thin, shiny atrophic skin; thick, ridged nails; loss of hair; ulcers; gangrene.

Examination mechanics: legs – venous pattern, edema, and symmetry

• Venous pattern:
  • Normally flat and barely visible; check for obvious varicosities, best assessed standing.
• Leg size symmetry:
  • Both legs should be symmetrical in size with no swelling or atrophy.
• Calf circumference for asymmetry:
  • If unilateral leg appearance is asymmetric or DVT is suspected, measure calf circumference with a tape at the widest point;
  • Record in cm and compare to the other leg at the same point.
  • If lymphedema suspected, measure at ankle, knee, and thigh as well.
• Abnormal edema signs:
  • Diffuse bilateral edema may reflect systemic illness.
  • Acute unilateral swelling with a 1 cm or greater asymmetry suggests possible DVT; refer for medical evaluation.
  • Asymmetry by degrees:
  • 1–3 cm: mild lymphoedema.
  • 3–5 cm: moderate lymphoedema.
  • >5 cm: severe lymphoedema.
• Skin discoloration and ulcers:
  • Note size and exact location of discoloration, ulcers, or gangrene.
• Venous vs arterial ulcers:
  • Venous ulcers: chronic venous insufficiency; usually associated with varicosities.
  • Arterial ulcers: caused by chronic lack of blood flow; tend to occur on tips of toes, metatarsal heads, and lateral malleoli.
• Special note on edema types:
  • Diffuse bilateral edema can occur with heart failure, diabetic neuropathy, and hepatic cirrhosis.

Hemodynamic findings: venous and arterial notes

• One-way valves and gravity:
  • Venous return relies on valves to prevent backflow when standing.
• Clinically important alerts:
  • Acute unilateral, painful calf swelling with asymmetry of 1 cm or more is abnormal; urgent evaluation for DVT.
  • Asymmetry of 1–3 cm: mild lymphoedema; 3–5 cm: moderate; >5 cm: severe.
• Brown discoloration:
  • Hemosiderin deposits from RBC breakdown due to chronic venous stasis.
• Limb ulcers:
  • Venous ulcers from chronic venous insufficiency; arterial ulcers from chronic arterial insufficiency.

Palpation and localization of leg pulses

• Posterior tibial pulse:
  • Palpate behind the medial malleolus; feel the tapping in the groove between the malleolus and the Achilles tendon.
  • If hard to find, try passive dorsiflexion of the foot to expose the pulse.
• Dorsalis pedis pulse:
  • Located just lateral to and parallel with the extensor tendon of the big toe; use a very light touch; do not confuse your own pulse with the patient’s.
• Age-related note:
  • In adults over 45 years, either the dorsalis pedis or posterior tibial pulse may be difficult to find, but rarely both on the same foot.
• Pulse comparison:
  • Palpation should reveal comparable strength bilaterally; discrepancies may indicate local problems.
• Doppler use for pulses:
  • When needed, a Doppler device helps detect a weak pulse, monitor BP in infants/children, or measure BP in a lower extremity.
  • Procedure with Doppler:
  • Place patient supine, legs externally rotated for easy access to medial ankles.
  • Apply a drop of coupling gel to the transducer tip.
  • Place the transducer over the pulse site at a ~45° angle and apply very light pressure.
  • Identify the pulse by listening for the swishing, whooshing sound.
• Doppler reference: See Chapter 10 for additional details.

Pediatric, obstetric, and geriatric considerations

• Infants and children:
  • Transient acrocyanosis and skin mottling at birth are discussed in Chapter 22.
  • Pulse strength should be strong and symmetrical; upper and lower extremities should have comparable pulses.
• Acrocyanosis in infants:
  • A vasomotor condition with persistent, painless, usually symmetrical cyanosis of distal parts (hands, feet, rarely face) due to vasospasm.
  • Weak pulses can occur with vasoconstriction and diminished cardiac output.
  • Full, bounding pulses may occur with patent ductus arteriosus due to large left-to-right shunt.
  • Diminished or absent femoral pulses with normal upper-extremity pulses may suggest coarctation of the aorta.
• Pregnancy (Additional objective data):
  • Expect diffuse bilateral pitting edema in the lower extremities, especially later in pregnancy (end of day, and in the third trimester).
  • Varicose veins common in the third trimester.
  • Clinical alert: Generalized edema with hypertension can indicate preeclampsia; refer to midwife, nurse practitioner, or physician for further assessment.
• Adults over 65 (Additional objective data):
  • DP and PT pulses may be more difficult to locate.
  • Age-related trophic changes (thin, shiny skin; thick, ridged nails; loss of hair on lower legs) can mimic arterial insufficiency.

History and pain profiling (Table 16.1)

• History profiles of pain in peripheral vascular disease differentiate arterial from venous symptoms:
  • Chronic Arterial Symptoms:
  • Location: Deep muscle pain, usually in the calf, but may be lower leg or dorsum of foot.
  • Caused by intermittent claudication.
  • Chronic pain with gradual onset after exertion.
  • Acute Arterial Symptoms:
  • Symptoms vary and may involve the distal limb or entire leg.
  • Character: Throbbing.
  • Onset: Sudden (within 1 hour);
  • Duration may continue.
• This table helps differentiate etiologies and informs urgency of assessment.

Practical implications and interpretation

• Clinical decision-making:
  • Use bilateral comparison to identify asymmetry and rely on a combination of inspection, palpation, and Doppler when needed.
  • Be mindful of signs that prompt urgent referral (e.g., suspected DVT, acute arterial occlusion, preeclampsia in pregnancy).
• Reliability and standardization:
  • Pitting edema grading (1+ to 4+) is widely used but not fully standardized; some clinicians also quantify edema by calf or ankle circumference.
  • When edema is present, measure at consistent points and use non-stretchable tape for reliability.
• Connections to other domains:
  • Skin changes and ulcers link to wound care and dermatology (skin color, trophic changes, ulcers).
  • Neurological findings may overlap with sensory loss in diabetes affecting arterial disease assessment.
• Ethical/practical considerations:
  • Early identification and referral for suspected DVT or arterial insufficiency protects patient safety.
  • In pregnancy, recognizing preeclampsia signs is critical to maternal-fetal health; ensure appropriate escalation.

Summary of key quantitative details to memorize

• Nail bed profile angle: $160^ op^ ext{o}$
• Capillary refill time (normal): $< 2 ext{ s}$ (blanch and observe return)
• Temperature, skin signs, and color changes relate to vasoconstriction vs vasodilation; recolor times reflect perfusion status.
• Capillary refill and venous filling tests:
  • Time for color to return to feet after leg elevation test: typically $ext{≤ }10 ext{ s}$
  • Time for superficial veins around feet to fill after sitting with legs dangling: typically $ext{≈ }15 ext{ s}$
• Pretibial edema grading: $1+ ext{ to } 4+$ (scale is commonly used but reliability varies)
• Ankle circumference for edema assessment: measure at 7 cm proximal to the midpoint of the medial malleolus with a non-stretchable tape
• Calf circumference: measure at the widest point to assess symmetry; compare both legs
• DVT concern threshold: acute unilateral calf swelling with asymmetry of at least $1 ext{ cm}$ or more is abnormal; severity categories for lymphoedema:
  • Mild: $1 ext{ cm} o 3 ext{ cm}$
  • Moderate: $3 ext{ cm} o 5 ext{ cm}$
  • Severe: $> 5 ext{ cm}$
• Pulse grading: 3+ (full/bounding), 2+ (normal), 1+ (weak), 0 (absent)
• Pulse landmarks: dorsalis pedis artery located just lateral to and parallel with the extensor tendon of the big toe; posterior tibial pulse behind the medial malleolus; brachial and radial pulses examined for symmetry
• Doppler usage: ultrasound device used with coupling gel at ~45° angle for pulse detection; transducer placed on site with light pressure
• Age-related notes: in adults > 45, one of DP or PT pulses may be hard to find, rarely both on the same foot
• Pregnancy-specific signs: generalized edema and varicose veins common in third trimester; preeclampsia risk if generalized edema with hypertension
• Elderly: trophic changes common with aging may mimic arterial disease; pulses may be harder to find