Peripheral Arterial Examination: A Comprehensive Guide and Considerations

Peripheral arterial examination is a crucial technique for assessing blood circulation in the limbs. It helps diagnose vascular diseases such as aneurysms, arterial occlusion, atherosclerosis, and more.

1. Examination Techniques

a. Palpation:

• Femoral artery:
  • The examiner stands on the same side as the limb being examined.
  • Place the tips of your fingers and gently press on the midpoint of the line connecting the anterior superior iliac spine and the pubic tubercle.
• Popliteal artery:
  • The patient lies prone with the knee flexed at 60-90 degrees.
  • The examiner stands opposite the limb being examined.
  • Using one hand, support the lower leg while relaxing the muscles in the back of the thigh. The other hand should be cupped and slightly offset, with the fingertips under the tendon of the sartorius muscle on the inside of the popliteal fossa. Examination can be done with both hands.
• Dorsalis pedis artery:
  • Located between the first and second metatarsals.
• Posterior tibial artery:
  • Located in the groove behind the medial malleolus.
• Axillary artery:
  • The examiner stands at the head of the patient, who has their arm extended.
  • Use the second, third, and fourth fingers to palpate in the axilla.
• Brachial artery:
  • Palpate the groove of the biceps muscle on the inside of the arm.
• Radial artery:
  • Palpate the radial artery groove in the wrist.

b. Palpation Considerations:

• Compare pulses bilaterally, noting:
  • Regular or irregular rhythm.
  • Strong, weak, fast, slow, difficult to palpate, palpable or not.
  • Hardness and elasticity of the vessel wall.
• When palpating a mass over an artery:
  • First suspect an aneurysm.
  • Characteristics of a mass suggestive of aneurysm:
    • Unilateral mass, well-defined, pulsating in sync with the pulse.
    • Notably, the mass may be expansile.
    • Placing a stethoscope over the mass will reveal a loud systolic bruit.
  • Mass related to arteriovenous fistula:
    • A palpable thrill sensation, intensifying during systole, with a tendency to spread upwards and downwards.

c. Auscultation:

• Listening for a systolic bruit suggests arterial narrowing.

2. Assessing the Nutritional Status of the Limb

• Skin evaluation:
  • Skin color: pallor, cyanosis, redness, yellowness.
  • Skin temperature: cold, warm, hot.
  • Gangrene: partial or extensive gangrene.
    • Partial gangrene in the fingertips or toes: Pay attention to changes around and under the nails.
    • Extensive gangrene: Blackened skin, edema, scattered blisters with bleeding.
• Assessing hair and nails:
  • Observing signs of developmental disturbances in toenails, fingernails, and hair. Signs include brittle nails, ridging, and sparse hair growth.
• Evaluating subcutaneous tissues:
  • These tissues typically become atrophic, forming wrinkles. When released, the wrinkles take a long time to disappear. Edema may also be present.
• Muscle atrophy:
  • A common occurrence. Muscles appear atrophied and flaccid. Document the degree of atrophy.
• Neurological examination:
  • Sensation: Assess whether sensation is present or absent, increased or decreased in the limb. Note the boundaries.
  • Motor: Observe changes in active and passive movement.

3. Tests for Evaluating Limb Ischemia

• OPPEL-BUERGER Test:
  • The patient lies supine with the legs extended. Elevate the leg for a few seconds, and observe for pallor of the foot.
• Vascular Exercise Test:
  • Use a dull object to draw a line from the thigh to the ankle.
• Vascular Exercise Test Results:
  • Normal: The drawn line will quickly regain its pink color.
  • Vascular disease: The drawn line will show a discontinuity at a specific point, indicating limb ischemia.

4. Diagnostic Imaging Techniques

• Doppler ultrasound: Helps identify the location and severity of narrowing, the presence of intraluminal elements, location and extent of stenosis, presence of thrombi, and direction of blood flow.
• Echo-doppler: Evaluates the morphological characteristics of atherosclerotic plaques, the presence and location of lesions.
• Angiography: A necessary examination for surgical interventions.
  • Seldinger technique: Direct puncture of the femoral artery for angiography of the aorta and lower limb arteries.
  • Brachial artery puncture: Angiography of the arterial branches of the aortic arch.
  • Des Santos technique: Direct puncture of the aorta through the lumbar region.
• Angiography Indications:
  • Peripheral arterial disease.
  • Chronic arterial occlusion.
  • Arterial stenosis.
  • Angiography immediately after surgery for occlusions.
• Angiography results:
  • Arterial phase: Images of arteries, the nature of luminal flow, arterial caliber, smooth or irregular borders of the arteries, the flexibility of branches, presence or absence of arterial occlusion, the presence of collateral circulation in case of occlusion.
  • Capillary phase: Obscure contrast medium network in the soft tissues.
  • Venous phase: Appears after 12 seconds and lasts about 22 seconds. Clear visualization as if the contrast medium was directly injected into a vein.

5. Common Vascular Diseases

• Vascular injuries:
  • Injuries affecting all three layers of the vessel wall can lead to external arterial bleeding or intravascular circulatory disturbances.
  • Bleeding injury:
    • Shock in the patient.
    • If the patient presents with a tourniquet above the injury site: Examine in the operating room, assess if the wound is still bleeding, and check for a pulse below the injury.
  • Injury with diffuse hematoma: When surrounding tissues are loose, the hematoma spreads rapidly, pulsates with the heart beat, expands, and a systolic bruit can be heard.
  • Injury with localized hematoma: Tightly bound surrounding tissues, usually found in the calf. The calf is tense, very painful, tender to palpation, and there are signs of compression of arteries and veins, resulting in loss of pulse below the injury and a cold, cyanotic foot.
  • Dry wound: Bleeding has stopped, suggesting vascular damage when the wound is located on the path of a blood vessel. Signs of downstream ischemia may be present.
  • Downstream ischemia: Cold limb, pallor, absent or weak pulse, decreased motor sensation.
• Aneurysm:
  • A round or oval mass located along the course of an artery, pulsating and expanding with the heartbeat, with a systolic bruit heard on auscultation.
  • Compression above the aneurysm may cause it to shrink. The pulse below the aneurysm is weak and slower than on the opposite side.
  • Aneurysm diagnosis: Ultrasound or angiography.
• Arteriovenous fistula:
  • Usually appears after 6-8 years of age.
  • Hemodynamic disturbance, exertional pain due to ischemia, edema or slow-healing ulcers, rarely palpable masses, thrill sensation at the fistula, systolic bruit, dilated veins below the fistula, pulsating like an artery. Pressing the artery above eliminates the pulsating sensation in the vein and the thrill sensation.
• Acute limb arterial occlusion:
  • Causes:
    • Thrombosis: Due to local thrombus formation.
    • Embolism: Due to a traveling thrombus from another location.
  • Clinical presentation: Sudden, severe pain, initially localized to a point along the course of the blood vessel, then spreading distally; complete loss of limb function. The extremity is cold, numb, completely paralyzed, and pulseless. If delayed, blisters may appear.
• Chronic limb arterial occlusion:
  • Causes: Buerger’s disease, atherosclerosis.
  • Clinical presentation: Intermittent claudication, a gradually decreasing walking distance, pain even when lying down, a sensation of tightness or burning throughout the foot.

6. Doppler Ultrasound

• In arterial stenosis: Identifies the location of stenosis, the percentage of stenosis, blood flow velocity through the stenosis, and the cause of stenosis.
• In aneurysm: Determines the location, extent of the sac, sac diameter, thrombus (due to altered flow creating a thrombus), relationship to adjacent organs, and complications of the sac.
• In arteriovenous fistula: Identifies the location, size, blood flow through the fistula, and vascular complications due to the fistula.

7. Angiography

• In arterial stenosis: Identifies the location, percentage of stenosis, cause, collateral circulation (enlarged branches carrying blood to the heart due to mechanical obstruction or increased pressure in the larger arteries).
• In aneurysm: Identifies the location, extent, diameter, relationship to other organs, and complications of the aneurysm.
• In arteriovenous fistula: Identifies the location; the diameter and flow velocity through the fistula cannot be determined.

8. Classification of Aneurysms

• True aneurysms:
  • Cause: Atherosclerosis.
  • The sac wall is the same as the arterial wall, resulting in a fusiform sac shape.
• Pseudoaneurysms:
  • Causes: Injury or inflammation of the artery.
  • The sac wall is not the same as the arterial wall.
  • Blunt trauma: Injury to the intima and media, resulting in a stretched, bulging appearance.

Note:

• Peripheral vascular examination is a crucial part of cardiovascular patient evaluation.
• Utilize appropriate examination techniques and diagnostic imaging to ensure accurate diagnosis and timely treatment of vascular diseases.
• Pay close attention to risk factors for vascular disease such as smoking, hypertension, hyperlipidemia, diabetes, etc.
• Always adhere to safety guidelines and regulations during examination procedures.

We hope this article provides you with valuable information!