| The arteries 329 | Clinical assessment of the arterial | circulation of the lower limb 329 | Conditions of the arteries 335 | Chronic arterial insufficiency of the | lower limb, 336 | Pulsatile swellings (aneurysms) 343 | Haemorthage 347 | Transient and permanent neurological | weakness, paralysis and bindness 347 | Cold, blue digits, hands and fest 350 ‘Techniques for examination of the arteries, veins and lymphatics are described before detailed descriptions of the history and clinical features of diseases that affect them, Mia =taal sala) PTC ig eur ar em ra Always examine the patient in a warm room. A. routine for assessment i listed in Revision pane! 10.1 Inspection ‘This is a key part of the vascular examination. Colour ‘The most notable feature of an ischaemic limb is, its colour. The skin may be as white as marble or show The arteries, veins and lymphatics The lymphatics 369 Conditions affecting the lymph glands 369 Large limbs 353 | Surgically correctable causes of Hl hypertension 354 | Intestinal ischaemia 354 | The veins 354 Clinical assessment of the venous ; circulation of the lower limb 354 } Lower limb venous disease 363 | varying degrees of redness or blueness, which becomes: ‘more obvious in the lower parts of the leg and the toes, (Figures 10.1-10.3). Excessive deoxygenation of the blood in the skin capillaries sometimes gives the foot a purple-blue eyanosed appearance, but the blue fades to white within a few seconds when the patient lies down. There may also be areas of blue streaks around, white patches (‘mottling’) in the foot. When mottling, becomes fixed, the atea of ischaemia is usualy inrevers- ible (Figure 10.1b). Pigmented skin masks these subtle colour changes, making the diagnosis of mild and moderate arterial insufficiency more difficult. Gangrene tums the skin a permanent blue-black colour, which is usually first seen in the toes (see page 339). Scars Itis important to note any sears indicating previ- ous vascular intervention on the limb: + Groin scars for femoral artery access + Medial thigh scars over the course ofthe long saphenous vein (indicative of vein harvesting for bypass surgery) 329‘The arteries, veins and lymphatics Figure 10.2 Alimb showing the red/purple changas of chronic ischaemia, NOTE: It is important to look at the bottom, back ‘and lateral surfaces of the heel, the ball of the foot Figure 10.1 THE ISCHAEMIC LIMB. 6) Tholot foot and kn or ho malo Tho sk, ospaily ver becomes pallid on elevation, (b) An ischaemic right leg with ‘the head of the first and fifth metatarsals must be fod esting ofthe sf tag eset rapectaad ae tse ac eto thotoos Fire 104) ‘+ On the medial aspect of lower leg just below the knee for popliteal access. + Onthe anterolateral or medial aspect of lower Jeg nea the calf for distal anterior tibial, posterior tibial or peroneal) artery acess + Behind the knee for popliteal artery access. + Around the posterior par ofthe leg fr short saphenous vein harvesting for bypass surgery. Pressure areas Very carefully inspect all areas subjected to pres- sure or trauma during walking or bed rest, because these are the frst sites to show evidence of oPhIe Figure 10.4 Anischaomie uber has developed betwoon changes, ulceration and gangrene the oes where one toe = pressing gail tne cerClinical assessment of the arte*al citculation of the lower mb Geek ROUTINE FOR ASSESSING THE ARTERIAL CIRCULATION Inspection Colour Venous filing Pressure areas and botwoon the digts Sears Palpation ‘Skin tomperature Capilary reiling time Palpato the pulses Auscultation Listen for bruits Measure the ankle brachial pressure index Special tests Buergor's angle Pressure necrosis causes thickening of the skin, @ purple or blue discolouration, blistering, ulceration or patches of black, dead, gangrenous skin. NOTE: Loss of halon the skin ofthe lower leg is a ign of ischaemia buts unreliable andl does not need tobe recorded Palpation Temperature ‘The skin temperature can only be assessed reliably if both lower limbs have been exposed to the same ambient temperature for a full 5 minutes. Uncover the limbs and perform some other part of the physical ‘examination to allow the skin temperature to adjust to the temperature of the surrounding air. ‘The whole limb should be assessed starting in the foot using one hand for each limb to compare which parts are warm or cold, and the level at which, these changes occur. A blue ar even red foot can be very cold, NOTE: Most clncians prefer to use the backs of their ingers to assess temperature as the cool, dry backs ofthe fingors are ideal tomporature sonsors. Capillary refilling Press on the pulp of a toe or finger for 2 seconds, release pressure and then observe the time taken for the blanched area to recover. This gives a crude indication of the rate of blood flow in the capillaries and the pressure within them, This time can be com- pared in both limbs. Venous filling In a warm room, the veins of a normal foot are dilated and full of blood, even when the patient is lying horizontally. In an ischaemic foot, the veins collapse and sink below the skin surface to look like pale blue gutters. This appearance is called ‘venous ‘guttering’ (Figure 10.3) andis especially notable when performing Buerger’s test (see Special tests below) Feel all the pulses Pulses are most easily felt where an artery is superficial and crosses a bone, In the neck, shoulder and upper limbs, the carotid, subclavian, brachial and both wrist arteries ate close to the skin and easy to palpate, The pulses in the lower limb should be palpated from proximal to distal in order to deter- rine site(s) of stenoses or occlusions. ‘The femoral pulse in the groin lies halfway between. the symphysis pubis (in the midline) and the anterior superior iliac spine; this is called the mid-inguinal point (Figure 10.5a). ‘The popliteal pulse can be difficult to feel because it does not cross a prominent bone and is not super- ficial. There are three ways to feel it, and all three need to be tried before deciding whether the pulse is present or absent: + The most convenient technique for feeling the popliteal pulse is to extend the patient's knee, and place both hands around the top of the calf, with the thumbs placed on the tibial tuberosity and the tips of the fingers of eachr ‘The arteries, veins and lymphatics {a) Site of the femoral pulse at the midinguinal point, halway between anterior superior ilac spine and pubic symphysis. For palpation, normally more than one finger is Used for palpation ofthis pulse. b) Palpating the popliteal pulse with the knee extended. c) The positon of the fngers in the ‘mialine whan foaling the popliteal pulse with the knoe fully extended. (d) Simuhtangous palpation of the dorsalis pedis ppulses using the pulps of the fingers. (o) Simultaneous palpation of the posterior tibial pulses. hand touching behind the knee between the examiner feeling the radial pulse to check for heads of the gastrocnemius muscle (over the synchronization. lower part of the popliteal fossa). The pulps Flexing the knee to 135° loosens the deep of all the fingers are then pulled forwards fascia and may make the lower half of the against the posterior part of the tibial condyle, artery easier to feel. The vessel is, however, trapping the popliteal artery between them and moved further from the surface by bending the posterior surface of the tibia ( 7 the knee, and this may make palpation of ©). The pulsating artery can be felt in the the upper half of the artery more difficult as midline. When in doubt, count any pulse it sinks into the large fat pad between the you feel against the rate detected by a second femoral condylesClinical assessment of the arte*al citculation of the lower mb ‘+ Itis sometimes worth turning the patient into the prone position and feeling along the course of the artery with the fingertips of both hands. NOTE: When the popliteal pulse is very easy to od), t may be anourysmal and the pationt should bbe examined for a contralateral popliteal anourysm as well as an abdominal aortic aneurysm. ‘The dorsalis pedis artery runs from a point on the anterior surface of the ankle joint, midway between the malleoli, towards the cleft between the first and second metatarsal bones (lateral to extensor hallu- «is longus) (Figure 10.5d). Ask the patient to extend their great toe towards them to identify extensor hallucis longus prior to palpating, In 10% of subjects, the anterior tibial artery is absent and replaced by a branch of the peroneal artery. ‘The posterior tibial artery lies one-third of the way along a line between the tip of the medial malleolus and the point of the heel, but is easier to feel 2.5 cm higher up, where it lies just behind the medial mal- leolus (Figure 10.50). Itisimportant to feel the dorsalis pedis and poste- tor tibial pulses in both limbs simultaneously. To do this, stand at the end of the bed or couch and feel the dorsalis pedis artery of each foot simultaneously by placing the pulps of all the fingers of each hand along the line of the artery, with your thumbs beneath the arch of the foot. From this position, the hands can be rotated over the foot until the pulps of the fingers lie in the groove between the Achilles tendon and the ‘medial malleolus. The pulps of the fingers can then be pulled up against the back of the tibia, trapping the posterior tibial artery against the bone. Assess the muscles and nerves Severe ischaemia causes a loss of muscle and nerve function, ultimately producing an immobile, numb limb. The sensation in the toes and dorsum of both fect should be assessed as conditions such as diabetes can have impaited sensation as a result of diabetic neuropathy rather than ischaemia. Auscultation Itis important to use your stethoscope to listen to the arteries in the neck, the abdomen, the groin and \ \ Figure 10.6 The common sites to hear brults over the arteries of the lower limbs, the thigh for bruits in all patients suspected to have arterial disease (Figure 10.6). Bruits are caused by turbulent flow beyond a steno- sis, or an irregularity in the artery wall. Do not press: too hard over a superficial artery with the bell of your stethoscope, as pressure can distort the flow and cause a bruit, Akoays remember to listen over the adductor canal NOTE: Before frishing the physical examination of the lower mb, you should measure the blood pres- ‘suro in oth arms to exclude significant subclavian co innominate artery disease, Special tests Buerger's angle (the vascular angle) Buerger’s angle is the angle at which the leg becomes white when it is raised. In a normal limb the toes stay pink even when the limb is raised to 0°. In an ischaemic leg, elevation to 15° or 30° for 30-60 seconds may cause pallor (Figure 10.12) and. venous guttering. An angle of less than 20° indi- cates severe ischaemia, This test is often more use- ful as a comparator and both limbs should be raised 333334 ‘The arteries, veins and lymphatics together; the ischaemic foot goes white, while the normal foot remains pink, After elevating the legs, patients should be asked to sit up and dangle their feet over the side of the bed. A normal foot remains pink, whereas an ischaemic leg will slowly turn from, ‘white (after elevation) to pink and then take on a suf fused purple-red colour (Figure 10.2). This is a result of reactive kyperaemia where the re-oxygenation of the hypoxic tissue results in the washout of vasodila- tor metabolites that have built up whilst the leg was: clevated causing dilatation of the arterioles. Pressure measurement with the Doppler flow detector Ahand-held Doppler ultrasound should be used to detect blood flow. The sound waves generated by the © THiohasic Foeward tow (hte diastole) Forward fow Fooward fow (opstcle) (site) Rovers fow (ate sso! cary diastole) device are focused into a beam and directed towards the vessel to be examined by placing the probe over the surface of the vessel, after removing any air between the probe and the skin with a coupling jelly. Moving red cells alter the frequency of the reflected, ultrasound according to the Doppler principle. The chosen vessels, usually the dorsalis pedis posterior tibial or peroneal arteries at the ankle, are located by placing the Doppler probe over their Known anatomical course and listening for regular changes in the sound generated by the pulsatile flow. A sphygmomanometer cuff previously placed around the ankle is then inflated until the noise created by the flow ceases (Figure 10.7a). The pressure at which, this occurs is the systolic blood pressure. This can be measured in all three ankle vessels, In addition, the Monophasic ‘Slow aceleraion and ooolraton a Reverse tow (at sytoto! cathy dastoe) Figure 10.7 DOPPLER PRESSURE INDEX. (a) The technique for measuring the ankle pressure index, which Is the pressure at which the eutf neads to be inated to abolish the noise of the arceral ow using a Doppler. (2) Triphasic Doppler waveform shows forward flow in systole, ravarse flow in late systole/early diastole and forward flow in lato diastole (normal vessel), The bishasic Doppler waveform does nol have forward flow in late diastole and can represent high-resistant flow (eyhich can also be found in normal vessels), The low res:stant monophasic waveform with slow acceleration and deceleration suggests arteral disease proximal othe site of the Doppler.‘quality of the signal should be determined as being either monophasic, biphasic or triphasic (Figure 10.7b). ‘A monophasic signal usually indicates compromised flow, usually from a calcified blood vessel. ‘The pressure indexis the ratio between the pressure ‘measured by this technique in an ankle vessel and the pressure in the brachial artery: It is normally 1.0, i.e. both foot and brachial artery pressures should be almost identical. Ratios above 1.1 indicate stiff, calei- fied limb vessels (often diabetic arteries), which can- not be compressed by the external pressure applied by the sphygmomanometer cuff Ratios below 1 indi- cate occlusive disease of foot vessels upstream, NOTE: The Dopoler ultrasound flow detector is a ‘very useful tool because it can detect pulsatile flow |when the pulse is impalpable to the fingers. Amore accurate assessment of the sovority of the disease can be obtained by measuring the pressure before and aftor oxerciso, Ce CRORE RE UCU ACUTE ARTERIAL INSUFFICIENCY OF THE LIMBS ‘This occurs when the arterial blood supply to a limb is suddenly interrupted, with no time for collat- crals ta form. It is much more common in the lower limbs, The pain comes from ischaemic muscles and nerves, which develop irreversible changes within a few hours Seek ‘THE SYMPTOMS AND SIGNS OF ACUTE ISCHAEMIA: THE 6 Ps Pain Paraesthasia and numbness Paralysis Pallor Pulsaless Parishing cold Conditions of the arteries Tre symptoms and signs are commonly known as the 6 Ps (Revision panel 10.2). The symptoms are: + Pain, usually very severe and of sudden onset + Paraesthesiae (pins and needles’) and numbness, which develop over a few hours and ‘eventually progress to + Paralysis ‘The three physical signs are: + Pallor + Pulselessness, and the limb feels + Perishingly cold to the touch, The limb looks white and feels cold. These find- ings can be compared with the appearance of the other side if the symptoms are unilateral. The capil- lary circulation is poor, with a prolonged refilling time. The veins are empty, and the limb may become blue and develop a blotchy, blue-white appearance. ‘The femoral pulse may be absent if the arterial occlusion is just above the division of the common’ femoral artery into the superficial and deep femo- ral (profunda) arteries, or present if the occlusion is situated more distally. Similarly, in the upper limb, the subclavian and axillary pulses may be palpable, whereas the distal pulses, for example, the brachial, wrist and ankle pulses, are not Muscle tenderness, a bad prognostic sign, espe- cially in the muscles of the anterior and posterior calf compartments, should be sought by gently pressing. the bellies of these muscles, A full neurological examination should concen- trate on power, sensation and reflexes (see Chapter 3) ‘The Doppler ultrasound probe should be used to confirm the absence of pulsatile blood flow in the peripheral arteries. ‘The leg becomes mottled and marbled ifthe isch- aemia persists, The muscles eventually become hard, and the skin begins to blister and develop gungrene, which usually starts in the toes before spreading proximally. The causes of acute limb ischaemia are shown in Revision panel 10.3. Examination Examine the heart and general circulation with care in a patient with sudden arterial occlusion, An arterial embolus is suspected if the patient is fibrillating, has had a recent heart attack or is known 335