GenSurg.nz

Vascular examination

Arterial exam

Expose: ARMS + LEGS + GROIN + ABDO

HANDS:

  1. Nicotine staining
  2. Nails-splinter haemorrhage
    • Endocarditis
    • SLE
    • RA
    • Vasculitis
  3. Radial Pulse
    • Rate + Rhythm

NECK:

  1. Carotid pulse-AF
  2. Aucultate Bruits
  3. Scar- Carotid Endart

ABDOMEN:

  1. AAA (N=<2.5cm)
  2. Renal Bruits
  3. Laparotomy Scar

OTHERS:

  1. DOPPLER
  2. ABPI
    • N=0.9-1.2
    • <0.7=claudication
    • <0.4=rest pain
  3. NEURO
    • Sensation
    • motor

DIABETIC FOOT:

  1. clawed toes
  2. flattened arch
  3. Decreased sensation (glove + stocking)
  4. dry + cracked skin
  5. atrophic
  6. infection

LEGS/GROIN: INSPECTION:

  1. Colour a. Haemosidoren b. Erythema c. Purple d. white
  2. ulcers a. location b. depth c. granulation
  3. trophic changes a. hair loss b. tissue loss c. dry
  4. scars
  5. varicose veins
  6. guttering of veins (suggests decreased art flow)
  7. between toes + back of foot

PALPATION:

  1. Capillary refill
  2. Temperature (bck of hand)
  3. Pitting oedema
  4. Pulses a. DP/PT/popliteal/femoral

AUSCULTATE:

  1. Aorta + femoral + popliteal for BRUITS

BEURGERS TEST/ANGLE

  • Angle to which leg must be raised before becomes white.
  • N = > 90 dgrs AND toes remain PINK
  • < 90 dgrs ischaemic leg
  • < 20 dgrs severe ischaemia
  • (angle is proportional to pressure in foot small vessels)

ISCHAEMIC  ULCERS:

  • tips of toes / pressure areas / punch out / deep/surrounding tissue cold

NEURPATHIC/DIABETIC  ULCERS:

  • Painless / punched out +/- surrounding tissue healthy

Venous exam

2 FEATURES OF VENOUS CIRCULATION:

  1. Adequate CROSS-SECTIONAL area to allow normal OUTFLOW from limb
  2. If VALVES ensure ONE-WAY flow

INSPECTION STANDING:

  1. Varicosities- (collapsed when lying)
  2. Venous stars
  3. Skin changes: a. Pigmentation b. Eczema
  4. ‘inverted champagne’ bottle look
  5. Venous ulcers / healed ulcers (medial gutter area) a. Painful b. Shallow c. Sloping edge d. Purple/blue
  6. Oedema

SAPHENA VARIX COUGH TEST:

  • 2-4 cm inferolateral to pubic tubercle
  • ask patient to cough
  • N= no impulse palpable
  • +ve test = smooth palpable thrill
  • indicates incompetent valve at SFJ

PALPATION (lying):

  1. Temperature
  2. Tenderness
  3. Induration
  4. Thrombosis
  5. Pulses (DP/PT/Pop)

TRENDELENBURG TEST: • Used to find how far up the incompetent valves are • Pt lying • Raise leg (to empty veins) • Place torniquet below SFJ (remove after 60sec) • Stand Patient • N = vein fills > 35 sec • If incompetent valves, the superficial veins fill IMMEDIATELY o If fills from ABOVE, then SFJ incomp. o If fills from below, then incomp below torniquet.

PERTHES TEST: • Used for assessing PATENCY of DEEP VENOUS system • Pt STANDS → veins fill → torniquet placed (mid thigh) → walk 5 mins • N = long saphenous veins collapse o Indicates deep veins competent + communicating veins patent • If unchanged = SFJ + communicating veins incompetence • If veins increase (and pain) = deep veins occluded

More detail Arterial

Examination

  • Inspection:
    • Trophic changes: Loss of hair over calf/toes/foot, Thickening of toenails (onychomycosis), muscle wasting, Thin skin, Pale legs, Ulceration/ gangrene
  • Feel:
    • Coolness in feet, cap refill
    • Feel all pulses – rate, rhythm, quality
    • Examine aorta
    • Listen to heart
    • Check BP bilaterally - 5% PAD pts have supra-aortic occlusive disease with diff arm pressures (Use higher of two pressures to calculate ABPI)
  • Special tests
    • ABPI
      • Calculate pedal pressure with cuff at ankle (use doppler)
      • Compare to brachial (again use doppler)
      • Values
        • Normal = 1-1.2
        • < 0.5 = Critical Ischaemia
      • ABPI = Pedal BP/Brachial BP

        • 0.9 Normal

        • 0.6-0.9 Claudication
        • 0.3-0.6 Rest pain
        • < 0.3 Critical ischaemia
      • DM leads to falsely high ABI due to arteriosclerosis
      • Wall calcification (in elderly / diabetics) should be suspected if ABI > 1.1
      • Usually triphasic, biphasic – 50% stenosis, monophasic 70%
      • Actual ankle pressure can be useful
        • < 50mmHg – severe disease
      • Toe pressures
        • Useful in when have non-compressible tibial artery (DM) - digital vessels spared & hence compressible
      • Small pneumatic cuff around toe & photoplethysmographic sensor
      • Values
        • Normal ≥ 0.7
        • Claudication 0.4
        • Rest pain, gangrene 0.1
        • If > 30mmHg – indicator that there is healing potential for ulcers
  • Buerger’s Test
    • Elevate the limb
    • Normally toes should stay pink at 90 degrees
    • In PVD: Leg becomes waxy/cadaveric, white (esp. on sole) ± Venous guttering appears if a finger is run along a vein
    • When the limb is lowered, the time it takes for the vein to refill is a good indicator of the degree of ischaemia (normal < 15secs)
    • Buerger’s angle = Angle to which the leg is raised to become white (or doppler pulses disappear) (< 20-30 degrees = severe PVD, often with rest pain)
    • Dependent rubor - When the limb is hung down there is reactive hyperaemia because the ischaemia produced by elevation result in maximum cutaneous vasodilation - Dark red cyanosis (blood in foot relatively stagnant, oxygen extraction high)
  • Also: evaluate pt for associated cerebrovascular/cardiovascular disease
    • Listen for carotid bruit

More detail Venous

  • Look

    • Areas
      • Examine in standing position with groin and leg exposed
      • Externally rotate each leg then turn around
      • As with the post-thrombotic limb, an incompetent GSV disrupts the capillary circulation around the ankle, which may lead to venous hypertensive changes in gaiter area
      • Distribution and extent of varicosities – esp. Saphenovarix
    • Presence of skin changes of chronic venous stasis
      • Varicose eczema
      • Lipodermatosclerosis = Fibrosis of s/c tissues with fat necrosis & chronic inflammatory changes → Hard tissue
      • Champagne leg
      • Hemosiderin pigmentation / hyperpigmentation
      • Induration
      • Ulceration (esp. at med ankle) ± surrounding white scarred areas (atrophie blanche)
      • Corona phlebectatica = Cluster of telangiectasia over the medial ankle (distended subdermal & intradermal venules)
      • Look for thrombophlebitis – 40% associated with DVT

  • Feel:

    • Pulses
      • Check arterial status – distal pulses
      • If not palpable – ABPI
    • Other
      • Feel for temperature differences
      • Check for pitting oedema
      • Look for scars from previous repairs/abdominal surgery
      • Veins tense on palpation & cough impulse may be elicited at SFJ
      • Saphena varix - soft compressible dilatation of GSV adjacent to SFJ

  • Special Tests

    • Cruveihier’s Sign
      • Thrill over saphena varix on coughing
    • Chevrier’s Sign
      • Impulse felt over SFJ if saphenous vein is distally percussed
    • Trendelenburg Test
      • Direct digital pressure over the SFJ preventing retrograde filling of the GSV
    • Brodie-Trendelenburg Test
      • Tourniquet test to identify the sites of reflux from deep to superficial vein systems
        • With pt lying:
        • Tourniquet applied to elevated limb just below groin
        • Patient stands up
        • Normal: vein fills within 35secs from below with tourniquet in situ
        • Rapid filling of veins below the tourniquet indicates short saphenous vein incompetence or an incompetent perforator distally
        • Tourniquet removed after 60 secs
        • If rapid filling from above, it is due to incompetence above the tourniquet (i.e. SFJ)
        • Tourniquet can then be repositioned distally to find the level of incompetence or two tourniquet can be used to define an incompetent communicating vein
        • Trendelenburg test becoming obsolete
        • Sensitivity for GSV incompetence = 55%, SSV incompetence = 35%
    • Perthes Test
      • Assesses patency of deep veins
        • Pt standing and veins filled
        • Tourniquet is applied to mid-thigh
        • Pt walks for 5 minutes
        • If Saphenous Veins collapse below the tourniquet = Deep veins are patent and the communicating veins are competent
        • If unchanged = Both saphenous and communicating veins are incompetent
        • If the veins ↑ in prominence and pain occurs = Deep veins are occluded
    • Hand-held Doppler Test:
      • Traditional tests have poor diagnostic value
      • Using hand-held doppler the examiner ask pt to wt bear on the contralateral leg
      • Locate femoral pulse then move medially – confirm vein by squeezing and releasing the calf to hear antegrade flow. Move inf to locate SFJ – squeeze calf to get antegrade flow and listen for reflux – can test SSV also
    • Pressure Changes
      • Normal
        • P drops from 90mmHg to < 20mmHg on 10s exercise
        • P returns to 90mmHg over > 20sec rest
      • Primary Varicose Veins
        • P drops from 90 mmHg to 20-40mmHg on 10s exercise
        • P returns in about 10s
      • Post thrombotic syndrome
        • P drop if present is minor (perhaps down to 60-70)
        • P returns in about <10s

        • 60 – risk of ulceration > 50%

    • Incompetent perforators
      • May be found clinically as gaps in the fascia → Aneurysm-like distension can be palpated as a soft compressible lump
        • INDIRECT – to a muscular deep vein
        • DIRECT – to one of the main deep veins
      • “Horny dogs breed chaos”
      • Hunterian – middle 1/3 of thigh (level of adductor canal)
      • Dodd – distal 1/3 of thigh
      • Boyd – around knee & upper 1/3 of medial calf – MOST COMMON
      • Cockett (I-III)– distal calf – connects to Posterior Arch Vein
      • Inframalleolar

  • Percussion impuls

    • Can palpate for a transmitted percussion impulse from above downwards → Implies absent / incompetent valves

  • NB: Relying on examination alone

    • Inappropriate surgery in 12-25%
    • Recurrence & re-op rate of 10% after 2 yrs (cf 2% if scanned)
    • Most pts with venous ulcers have incompetent communicating veins

Evaluating a diabetic foot

History

  • Duration of diabetes, overall glycaemia control, presence of micro/macrovascular disease
  • History of foot injury
  • Claudication symptoms
    • Seldom get claudication as disease mostly infragenicular
  • Smoking
  • History consistent with foot neuropathy - burning pain in feet, wakes at night, worst at night, relived by walking around.

Examination

  • Inspect
    • Lesions between toes, bunions, macerated areas.
    • Claw-foot deformity
    • Look for signs of infection
    • Assess gait
  • Feel
    • Evaluation of pedal pulses
    • Test sensation - Semmes-Weinstein monofilament - 12 sites of the foot. Test vibration at dorsum of first toe just proximal to nail bed.
  • ABPI - normal is 0.9-1.3
    • < 0.9 = PVD
    • < 0.4 = 0.4 critical limb ischaemia
  • PVD examination
  • Ulcer
    • Neuropathic ulcers: occur @ MTP heads or dorsum of toe, foot is typically warm with bounding pulses and distended veins
  • Neuro-ischaemic: occur @ tip of toes, heel and medial aspect of 1st metatarsal
    • No overlying callus, rim of ischaemic tissue around and often necrosis
  • Pain will depend on underlying neuropathy
  • Gangrene – dry (not infected) can be left and will autoamputate eventually
  • Wet gangrene (infected) will require debridement and often amputation
  • Infection: Cellulitis &/or osteomyelitis
  • Systemic signs of infection may be absent
  • Probe to bone – if +ve – PPV for osteomyelitis 50-65%

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