Vascular Examination

1. Vascular Examination Ashley Southall Sept 2005

2. Overview Quick anatomy Quick pathology Scheme for examining peripheral vascular system

3. Anatomy Arterial and venous systems

4. Arterial anatomy Aorta Common iliacs External iliacs Common femoral Superficial femoral Popliteal Anterior and Posterior Tibials Peroneal Dorsalis pedis

5. Pathology Atheroma and occlusion Aneurysms Skin changes e.g. ulcers, gangrene

6. Examination Necessary equipment Introduce yourself Privacy Position Light Expose

7. Examination N I P P L E

8. Examination Necessary equipment Introduce yourself Privacy Position Light Expose

9. Examination Full cardiovascular exam Claudicants 20% 5yr mortality Assess fitness for surgery In exam tell this to examiner at end

10. Inspection Look around the bedside for clues Tablets/ inhalers/ sprays Oxygen Heparin pumps Artificial limbs Insulin pumps/ syringes Cigarettes!

11. Inspection Inspect the patient as a whole In pain? General appearance

12. Inspection Hands Nicotine staining of fingers Amputations

13. Inspection Abdomen / groins Obvious pulsatile mass (AAA) Scars AAA repair Fem-pop bypass

14. Inspection Legs Scars Pallor Venous guttering Discoloration Ulcers

15. Inspection Pressure areas Malleoli Heel Ball of foot Head of 5 th metatarsal Tips of the toes Between toes

16. Palpation Temperature (back of hand) Capillary refill Pulses

17. Palpation Pulses Femoral Popliteal Dorsalis pedis Posterior tibial

18. Palpation Femoral pulse Landmark – mid-inguinal point

19. Palpation Popliteal pulse Place thumbs on tibial tuberosity Press fingers firmly into lower part of popliteal fossa

20. Palpation Dorsalis pedis Starts midway between the malleoli anteriorly (continuation of ant. tibial) Runs to cleft between first and second metatarsal bones

21. Palpation Posterior tibial Behind the medial malleolus

22. Palpation Test muscle power and sensation Palpate for AAA

23. Auscultation Listen for bruits Abdominal aorta Renal arteries Iliacs / femorals Adductor canal (2/3 down antero-medial thigh)

24. Other Buerger’s angle Support the patient’s heel Ask pt to raise leg to 90 ° Should stay pink to 90 ° Foot pale at 50° = severe ischaemia Foot pale at 25° = critical ischaemia

25. Other Swing legs over edge of bed If legs go engorged and purple, Buerger’s test = positive

26. ABPIs Ankle Brachial Pressure Index Take BP in both arms with Doppler US probe Take BP with cuff around lower leg using a Doppler US probe (highest cuff pressure at which pulse can be heard) Leg BP/ Arm BP = ABPI

27. ABPI Clinical status ABPI Symptom free 1 or more Intermittent claudication 0.95 - 0.5 Rest pain 0.5 - 0.3 Gangrene and ulceration <0.2

28. Venous Exam Lower limb venous anatomy Superficial and deep systems Long and short saphenous systems Perforators with valves Deep system within leg muscles

29. Inspection Expose patient (both legs visible to groin) Stand patient up Inspect the leg

30. Inspection Look for Varicose veins Venulectasias (small venous stars) Haemosiderin deposits Lipodermatosclerosis Ulcers Venous eczema Scars – previous ulcers, surgery Thrombophlebitis

31. Palpation Palpate varicosities Palpate saphenofemoral junction Locate femoral artery Mid-inguinal point halfway between ASIS and pubic symphysis Femoral vein lies approx 1cm medial to this (NAVY)

32. Palpation Saphenofemoral junction lies approx 2cm below this. Keep one hand on saphenofemoral junction Tap varicosity If saphenofemoral junction is incompetent, thrill may be felt

33. Palpation Doppler test Place probe over SFJ Compress varicosity Whoosh heard as vein compresses If incompetent long whoosh heard when released

34. Palpation Can also do this for sapheno-popliteal junction

35. Palpation Trendelenberg test Lie patient down Raise leg to empty varicosities Apply pressure to SFJ to occlude it Maintain the pressure while getting the pt to stand If varicosities do not refill, saphenofemoral incompetence is present

36. Palpation Tourniquet test As for Trendelenberg Apply tourniquet to upper thigh Stand patient up If varicosities fill, level of incompetence is below the tourniquet

37. Palpation Repeat the test with the tourniquet at different levels Level of incompetence between lowest tourniquet level at which veins still filled and level of tourniquet when veins controlled

38. Further tests Full abdominal exam Arterial exam Duplex ultrasound scanning

39. Thank you