Vascular Assessment

The Cardiovascular System

Steven Walmsley
Introduction to
Podiatry
Lecture 10

Acknowledgement to Stef Penkala and Haydar Oscan for

the original content of this material and diagrams sourced
Copyright 2003 Pearson Education, Inc. publishing
from Pearson education as Benjamin Cummings

1
Learning Outcomes
Understand and distinguish relevant skills in assessment
of vascular conditions

Tutorial
Cursory physical examination of the vascular system

2
 The Cardiovascular
System
A closed system
The heart pumps blood
Blood vessels allow blood to
circulate to all parts of the
body
The function of the
cardiovascular system is to
deliver oxygen and nutrients
and to remove carbon dioxide
and other waste products

Diagram from 2003 Pearson Education, Inc. publishing as Benjamin Cummings

3
4
 Blood Vessels: The Vascular System

Taking blood to
the tissues and
back
Arteries
Arterioles
Capillaries
Venules
Veins
There is also a lymphatic
Diagram 2003 Pearson Education, Inc. publishing as Benjamin Cummings
system 5
Differences Between Blood Vessel Types

2 - 9 mm ~ 4 mm
External and internal External and internal
jugular & femoral veins carotids & femoral arteries

Walls of arteries are the thickest

Lumens of veins are larger
Capillaries (One cell thick walls) allows for exchanges
between blood and tissue
Diagram 2003 Pearson Education, Inc. publishing as Benjamin Cummings

6
7
8
 Capillary Beds
Exchange nutrients
from blood to tissue
Capillary beds
consist of two types
of vessels
True Capillaries (flow
controlled by
precapillary
sphincters)
Vascular shunt
directly connects an
arteriole to a venule Diagram 2003 Pearson Education, Inc. publishing as Benjamin Cummings

Figure 11.10
9
10
Movement of Blood Veins

Most arterial blood is

pumped by the heart
Veins use the milking
action of muscles to
help move blood
Working against
gravity
Valves prevent back
flow
Respiratory pump
Cardiac Suction
Figure 11.9
diagram 2003 Pearson Education, Inc. publishing as Benjamin Cummings

11
 The Heart: Cardiac Output

Cardiac output (CO)

Amount of blood pumped by each side
of the heart in one minute
CO = (heart rate [HR]) x (stroke volume
[SV])
Stroke volume
Volume of blood pumped by each
ventricle in one contraction
Diagram 2003 Pearson Education, Inc. publishing as Benjamin Cummings

12
 Cardiac Output

CO = HR x SV
5250 ml/min = 75 beats/min x 70 mls/beat
Norm = 5000 ml/min
Entire blood supply passes through body
once per minute.
CO varies with demands of the body
ie exercise, stress, thyroxine, epinephrine, CHF
etc
Diagram 2003 Pearson Education, Inc. publishing as Benjamin Cummings

13
Congestive Heart Failure (CHF)

Decline in pumping efficiency

of heart
Inadequate circulation
Progressive, also coronary
atherosclerosis, high blood
pressure and history of
multiple Myocardial Infarctions
Left side fails = pulmonary
congestion and suffocation
Right side fails = peripheral
congestion and edema
14
Diagram 2003 Pearson Education, Inc. publishing as Benjamin Cummings

 Cardiac Output Regulation

Diagram 2003 Pearson Education, Inc. publishing as Benjamin Cummings

Figure 11.7 15
 Regulation of Heart Rate
Increased heart rate Decreased heart rate
Sympathetic nervous Parasympathetic nervous
system system
Crisis
High blood pressure or
Low blood pressure blood volume
Hormones Decreased venous return
Epinephrine
In Congestive Heart
Thyroxine Failure the heart is worn
out and pumps weakly.
Exercise
Digitalis works to provide a
Decreased blood volume slow, steady, but stronger
beat.
16
The arteries and
veins of the lower
limb

Picture From Merrimans

assessment of the lower limb
(2009)

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 Arterial supply to the foot

Femoral artery

Popliteal artery
and the musculoskeletal system (2006)
Atlas of anatomy general anatomy

Scheunke, Schulte, Schumacher

Posterior tibial artery

Anterior tibial artery

Dorsalis pedis artery

18
 Arteries on the
dorsum of the foot

Anterior tibial
Arcuate
and the musculoskeletal system (2006)

Dorsalis pedis
Atlas of anatomy general anatomy

Scheunke, Schulte, Schumacher

Note the
relationship to
ankle and the
metatarsals for
identification
19
Atlas of anatomy general anatomy
and the musculoskeletal system (2006)
Scheunke, Schulte, Schumacher

vein and tibial nerve

20
Posterior tibial artery,
Vascular Assessments

21
Patient History
Presenting Complaint
Pain (activity versus rest pain), cramps, numbness,
coldness, tenderness, burning, fullness and pallor,
oedema
IS this related to the vascular supply?
On clinic you will need to Rule out: Neuropathy, arthritis,
anaemia, trauma, musculoskeletal abnormalities ( more of this
in latter years of your study).
Intermittent Claudication
Changes with fast vs slow walking
Changes with up or down hill
Distance walked before pain occurs
Correlation with pain and occlusion
Rest Pain
End stage
Non- healing lesion
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 Hx of Cardiovascular disease
Do they have a hx of Symptoms and signs
Ischemic heart disease Chest pains
Angina SOB
Heart attack ( myocardial infarction) Palpitations
High BP Ankle swelling

Congestive heart failure Faints

Valvular Leg cramps

Myocardial etc

Hypertension
Irregular heart rhythms
Bradycardia
Ventricular tachycardia ( cardiac arrest)
Rheumatic fever
Deep venous thrombosis/ pulmonary embolism
Peripheral artery disease, diabetes etc 23
 Disease risk threshold factors
Family history- myocardial infarct
Smoker
Hypertension
>140/90 or antihypertension meds
Dyslipidemia
low density > 3.4mmol/L, High density
<1.03mmol/L
Impaired fasting glucose
>5.6mmol/L
Obesity
Sedentary lifestyle
 Signs and Symptoms Health risks
Chest, neck, etc pain Cardiac disease (coronary artery disease)
Shortness of breath At rest or mild exertion cardiopulmonary disorder
(SOB) (left ventricular dysfunction or COPD )
Dizziness, syncope Cardiac disease
Orthopnoea, paroxysmal Left ventricular dysfunction
nocturnal dyspnea
Ankle odema or leg Bilateral at night- heart failure or bilateral chronic
cramps venous insufficiency
Palpations , tachycardia Disorder of cardiac rhythm, anxiety, high cardiac
output states (fever, thyrotoxicosis, anaemia)
Intermittent claudication coronary artery disease (diabetes prone)
Known heart murmur Hypertrophic cardiomyopathy, aortic stenosis risks

Unusual Fatigue, SOB Decline CV, pulmonary or metabolic disease status

with usual activity
History (Hx)
Medication risks
Social Hx NSAIDS ( Non- steroidal anti-
inflammatory drugs)
Smoking Risk of heart attack
Some taken off the market
Alcohol
2004 Merck Sharpe & Dohme
Psychosocial stresses announced an immediate
voluntary worldwide
Socioeconomic withdrawal of rofecoxib (Vioxx)
status
Diet Indications of CVD
Diuretics
Weight
Beta-blockers
Exercise Calcium antagonists
Statins
Anti-platelet 26
 Physical Examination
Observation
Skin Appearance
Temperature
Hair Growth (No hair can represent poor blood supply)
Nail quality (Clubbing can indicate cardiac problems)
Colour
Pallor on elevation and rubor with dependency
It is the vascular supply which maintains tissue viability
Palpation of Pulses
Femoral, Popliteal, Dorsalis Pedis, Posterior Tibial
Doppler, Ankle Brachial Index (ABI)
Buerger's , Venous filling tests etc
General
Heart Rate HR, Blood Pressure BP, VITAL SIGNS

27
Observation- venous
Varicose veins
Locations
Severity
Oedema
Pitting vs. non-pitting
Venous conditions
Tissue fluid re absorption
Chronic heart failure
Lymphatic conditions
Haemosiderin deposits
Iron deposits
Telangiectasia
Spider veins
Physical Examination
Skin
Compare limbs
Normal vs Thin, brittle, shiny
with thick or thin opaque toes
(Observation)
Cool vs warm,or if hot
(inflammation)
Normal vs Poor Hair
distribution
Colour ( pink vs pallor,
cynosis, rubor, black)
Odema
Muscle Bulk (Asymetrical
atrophy) 29
 Interpretation of colour changes
Pink Healthy (WNL)
White. Pale ( pallor) Cold, ( to conserve heat) anemia, chillblains, raynaulds
phenomenon, cardiac failure, insufficient arterial supply,
occlusion (precursor to gangrene)

Blue (peripheral) (deoxygenation) Cold, chillblains, raynaulds phenomenon,

venous statis
Blue with central Cardiac, respiratory failure
cyanosis
Hazy blue Infection, necrosis, bruising
Red Heat, exercise, extreme cold (cold-indiced vasodilation),
inflammation, infection (cellulitis), chillblains, raynaulds
phenomenon.
Dusky red (severe vascular deficiency)
Brown Haemosiderin deposits, necrosis, melanoma, gangrene
Black Bruising, shoe dye, necrosis, melanoma, gangrene
From Merrimans Lower limb assessment 30
 Examinations
Temperature
Back of hand (Why?)
Anterior. Tibial border to digits 1-2C decrease in
temperature
Influences on temperature
Neural
Nicotine
Caffeine
Vascular
Inflammation
Environment
etc
 Physical Examination
Pulse exam
Palpable vs. non-palpable
Audible by doppler vs. not audible
Assess regularity (number of beats
per min)
Assess phasic pattern (mono, bi, tri-
phasic)
Compare limbs
Pulse exam helps define level of
disease
May also examine pulses after
exercise
In podiatry we mostly palpate the
dorsalis pedis (DP) and the Posterior
Tibialis (PT)
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Pulses

Compare limbs
Regular/irregular
Strong/weak
Grading
0 - no pulse
1 - very poor
2 poor/weak
3 Normal
4 bounding
 Pedal Pulses
DP and PT pulses are not palpable in 8% and 2% of the normal
population ( however often and find them with doppler)
We are interested in pedal pulses to detect peripheral vascular
disease (PAD)

Both DP and PT absent High likelihood ratio (3 to 3.8x more likely to have PAD)
Absent DP or PT Not predictive of PAD
Small percentage is normal presentation
Present DP and PT Doesnt rule out PAD
30% of diabetic persons with severe PAD have a palpable PT
or DP pulse due to collateral blood flow
If a hx of claudication, poor colour + skin viability requires
further vascular testing

JAMA 2006; 295:536 Arch Intern Med 1998; 158:1357 Diabetes Care
2003; 26:3333
34
Non Invasive Arterial Testing
Doppler

Normal scenario

Multiphasic
Pulsatile
Regular Amplitude
35
Diagram from Merrimans assessment of the lower limb 2009 Doppler
Triphasic
1st sound the loudest had
highest peak (systole)
2nd and 3rd sounds (diastole),
reversal of flow elastic
distension of artery, and final
forward flow with artery rebound
Biphasic
Loss of rebound ( can occur with
age reduced vessel
compliance)
? stenosis
Monophasic
Diminished vessel elasticity of
the vessel. PAD

36
 Photoplethysmography (PPG)
Light emitting diode
measures haemoglobin in tissue www.hokanson.cc

Small cuff occludes blood flow to

toe
Similar to blood pressure
systolic pressure
> 50-55mm Hg adequate for toe
healing
Reflects red blood flow through
sub papillary venous plexus
Avoids elevated readings from
calcification of larger arteries
Able to calculate TBI (Toe Brachial
index) >0.7OK http://www.algeos.com/acatalog/SD30EX.jpg
38
Diagram from Merrimans assessment of the lower limb 2009

Ankle Brachial Index (ABI)

Useful noninvasive test to diagnose PAD in diabetes 39
40
41
Diagram from Merrimans assessment of the lower limb 2009 Ankle Brachial Index (ABI)
Ratio of Systolic Blood
Pressure Ankle/Arm
(Brachial) (A/B)
Normal ratio >1.0
Can also be calcified arteries
Claudication 0.8-1.0
Ischemic Rest Pain <0.8

Results may be skewed by

diabetes
ie calcified arteries

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Diagram from Merrimans assessment of the lower limb 2009

43
 Elevation Tests

Capillary Refill Time < 3 to 5 seconds

Buerger's Test (1 minute)

Venous Filling Time ( <20 seconds)

44
Capillary Refill Time < 3 to 5 sec
Quick and easy to perform
But not really useful
Lacks sensitivity
Moderate specificity
Really the sub papillary venous plexus
Elevate limb above heart level
Refill time
< 3 sec on a cold day
<5 sec on a warm day
Prolonged colour return
(compromised circulation questioned

45
Venous filling time < 20 seconds
Time to refill the pedal veins
after elevation
Determined by vascular and
venous patency
Specific but not sensitive for
the detection of PAD
Technique:
Sitting: ID pedal vein bulging above
skin
Supine: Elevate leg to 45 for 1 min
Sitting: time to pedal vein bulging
above skin
46
 Buerger's Test (1 minute)
When the vascular supply is normal ,
the skin on the feet is pink.

With elevation (1 minute), the colour is

maintained with some blanching.
On dependency normal colour
returns in 15-20s

If there is marked pallor (whiteness),

ischemia should be suspected
On dependency , return of colour
> 20s (PAD).
If Rubor, serious ischemia
(reactive vasodilation hypoxic)
Sensitive but not specific
47
Abnormal test Sensitivity % Specificity %

Buergers test WNL rules out disease 100 54

Venous Filling Predicts Disease if 22-25 94-95
Time (>20s) prolonged.
But normal test does not
exclude disease
Capillary refill Moderate predictor when 25-28 84-85
(>5s) disease prolonged. Normal
does not exclude disease
Doppler Abnormal ( disease highly 8 96
(<50mmHg) likely)
ABI (<0.9) Vascular disease 83 100
100 88

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Other Tests
Referral to local Dr/ specialist

Non Invasive
Dublex US
Invasive Test
Arteriography
MRI
3D CT Scan
Surgery

49
 Arteriography
Advantages
Gold standard for demonstrating
anatomy of disease
Provides therapeutic opportunities
Disadvantages
Invasive: risk of haemorrhage,
aneurysm, infection
Contrast load is nephrotoxic

50
 Duplex Ultrasound
Advantages
Non-invasive
Fast/cheap
Few complications
Disadvantages
Operator dependant
Poor visualization below the
knee

51
Magnetic Resonance imaging (MRI)
Advantages
Good resolution
Allows visualization of surrounding structures
Non-invasive with few complications
Disadvantages
Efficacy has not been demonstrated
Cost/availability

52
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