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Examination in Arterial Diseases
https://t.me/med1917
Examination in
111
5
Arterial diseases commonly occur in lower limb and
also occasionally in upper limb. Often both lower and
upper limbs may get involved. It is often classified
as lower limb ischaemia and upper limb ischaemia.
But wherever is the disease detailed examination of
both lower limb and upper limb vessels are required
in all patients.
Name:
Age:
Sex:
Occupation:
Address:
Atherosclerosis usually occurs in old age.
Thromboangiitis obliterans (Buerger’s disease, T AO)
occurs in young males. Even though congenital,
cervical rib syndrome is seen in middle aged individuals. Raynaud’s disease is common in young/middle
aged females. TAO occurs commonly in lower limb.
Upper limb is involved only if there is lower limb
disease. Atherosclerosis involves lower limbs.
Raynaud’s disease occurs in upper limb. TAO and
Raynaud’s disease are commonly bilateral. Arterial
embolism is unilateral causing sudden gangrene.
Atherosclerosis often is unilateral to begin with; but
eventually becomes bilateral. TAO is not observed/
very rare in females. Atherosclerosis can occur in both
sexes but more common in males. People working
on vibrating tools/machines are prone to develop
Raynaud’s syndrome. Raynaud’s disease is more
common in women. Cervical rib is more common in
females. Thoracic outlet syndrome is more often seen
in swimmers, volleyball players, painters, carpenters.
Arterial Diseases
Chief Complaints
Pain in the limb right/left/both—its duration.
Intermittent claudication—its duration.
Blackish discolouration/ulceration.
History
History of Present Illness
Pain
Site of pain, type of pain whether—severe burning/
aching/deep persisting type is asked. Whether pain
radiates (along the course of artery) or not; history
of intermittent claudication—its duration, grade/how
much distance patient can walk without pain/ whether
pain subsides after walking is stopped or after continuous walk/whether patient is able to walk in spite
of pain/whether there is any change in the claudication
distance/site of claudication—foot/leg/thigh/buttock;
Presence of rest pain—its location/severity/whether
the pain gets relieved a little bit by holding the limb/
foot/leg/toes (pain slightly lessens probably by
transmission of temperature from holding hand into
the part) or hanging the leg down or by applying the
warmth (Fig. 5.1); history of pain, discomfort, colour
changes when exposed to cold is especially significant
in upper limb ischaemia. Application of warmth may
worsen the arterial occlusion symptoms. Painful part
is very sensitive and pain is precipitated/aggravated
by any movement/touch or pressure sensation.
Limitation of walking—as the result of muscle pain
is an important complaint.
Ulceration
Whether precipitated by trauma/spontaneous onset;
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Fig. 5.1: Rest pain in a TAO patient. Observe the way
patient is holding the foot to relieve the pain.
SRB’s Clinical Surgery
duration; progression; pain in the ulcer/type/duration/
aggravating or relieving factors; type of discharge—
serous-purulent-bloody should be asked.
Gangrene
Site of gangrene/its onset/progression/pain has to be
asked (Figs 5.2A to D).
History of difficulty in walking/altered gait: Duration
of such disability and progress; whether it interferes
with his routine work; whether patient is bedridden
due to severe symptoms has to be noted.
Mode of onset: In atherosclerosis/Buerger’s disease,
process of disease is spontaneous and gradual.
Gangrene due to embolism is sudden in onset, rapidly
progressive with radiating severe pain along the artery.
History of fever: Diabetic gangrene or wet gangrene
may be associated with fever due to associated
bacteraemia or localised suppuration.
A
B
C
Figs 5.2A to D: Gangrene toes, pregangrenous changes in some toes, gangrene leg, ischaemic changes.
Always inspect the plantar aspect of the foot in all patients with peripheral vascular disease.
D
Examination in Arterial Diseases
https://t.me/med1917
History of impotence: Its duration has to be asked
[due to bilateral internal iliac artery (aortoiliac) block
(Leriche syndrome)—present with pain in buttock;
impotence, aortoiliac block].
History of tingling/numbness/weakness in the limbs/
pins and needles sensation in the skin of foot and legparaesthesia due to shunting of cutaneous blood to
deeper muscles.
History of syncope/blackouts/loss of consciousness/
blurred vision/transient ischaemic attacks (due to
carotid vessel block)/abdominal colic with bloody
stool—features of involvement of other arteries.
History of chest pain/cough or cardiac related
symptoms.
History of abdominal pain/bloody diarrhoea/abdominal angina or colicky pain.
History of paraesthesia over the skin due to shunting
of blood from skin to muscle.
History suggestive of superficial thrombophlebitis
like swelling/redness/pain along the line of superficial
vein.
Past History and Treatment History
History suggestive of similar complaints in the past;
history of drug intake earlier for similar conditions
like vasodilators/drugs to increase the perfusion;
history of surgeries like sympathectomy/omentoplasty
in the past/their results or effects are to be noted
(Fig. 5.3).
113
Personal History
History of smoking—beedi or cigarettes/duration of
smoking/number of cigarettes per day/whether smoking is discontinued and since when.
Family History
Any family history suggestive of atherosclerosis or
vascular diseases or diabetes mellitus should be asked.
General Examination
Pulse-rate/rhythm/character/condition of vessel wall
is noted; blood pressure of both arms and if possible
of both lower limbs is checked; attitude of limbs is
noted. Other detailed general examination is very
essential. Anaemia /pedal oedema/jaundice/clubbing/
lymphadenopathy/raise in temperature/attitude of the
patient/nutritional assessment by skin texture,
subcutaneous fat, weight, body mass index/any other
relevant findings should be mentioned.
Local Examination
Inspection
Inspect both lower limbs keeping side-by-side as
comparison is needed during clinical examination.
Inspect entire length of the limb.
Change in colour of limb is very important sign of
ischaemia. Pallor should be observed by keeping both
limbs adjacent. Marked, sudden severe pallor suggests
acute arterial obstruction like embolism. Presence of
cyanosis/purple colour/congestion/blackish discolouration and its extent should be observed. Colour
proximal to gangrene area/ischaemic area (usually
ischaemic area is paler) should be noted.
Fig. 5.3: Lumbar sympathectomy scar with ischaemic
ulcer foot showing healing sign.
Limb deformity—Its severity, gait, and attitude is
noted.
Gangrene of toe/toes/foot/leg—Its extent, dischar ge
from area, type of gangrene—dry or wet, line of
demarcation—type/level/depth , colour of gangrenous
area-black/purple/greenish black; reddish black [in
gas gangrene (H2S)]; odour of discharge from gangrenous area is noted.
Ulceration if any—its extent/discharge/size/shape/
floor/surrounding area is noted. Patchy ulcers proximal
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SRB’s Clinical Surgery
to gangrenous area—skip lesions which are usually
black patchy lesions should be looked for.
Muscle wasting in the foot/leg/thigh should be
observed. It should be compared with the other limb
and also should be measured using a tape from a fixed
bony point keeping equal distance in both limbs (Fig.
5.4).
Fig. 5.4: Wasting of muscles of right hand because of ischaemia. Also note the colour difference between two hands.
Features of ischaemia such as thin shiny skin/loss
of subcutaneous fat/hair loss and its extent/nail changes
like brittle nail/transverse ridges in the nail should
be noted. Superficial small ulcerations; ulcers on
pressure areas should be noted. Plantar aspect of the
foot should be inspected for any infective focus/
abscess/callosities/skin changes/superficial ulcers in
heel/malleoli/toes (Figs 5.5 and 5.6).
Line of demarcation is the line between viable and
non viable tissue. It is defined by a band of hyperaemia.
Fig. 5.6: Ischaemic changes in the right leg. 3rd and 4th
toes are gangrenous with line of demarcation. Great and
little toes are partly gangrenous. There are ischaemic features
in the right foot and leg like hair loss/skin changes/wasting.
Line of demarcation is well defined in dry gangrene.
It is ill defined and unclear in wet gangrene.
Buerger’s postural test: Patient in supine position is
asked to raise his legs one after another with knee
kept straight. Normal limb remains pink even after
90° elevation without any pallor. Diseased limb shows
marked pallor after elevation (over foot) with empty-
guttered veins. The angle at which pallor develops
(between limb and ground) is called as Buerger’s
vascular angle of insufficiency. In severe ischaemia
this angle will be less than 30°. If foot does not become
pale or when doubtful, repeated ankle flexion and
extension is done until it becomes pale (cadaveric
pallor) with empty-guttered veins on the dorsum of
foot and cyanotic congestion appears after lowering
the foot in 3 minutes.
On elevation pallor and blanching occurs (elevation
pallor); on dependence reddish purple congestion may
occur (dependency rubor).
Oedema in the foot/feet/legs suggests inflammation/
congestion.
Fig. 5.5: Gangrene of all toes at their distal phalanges.
All ischaemic features are obvious.
Status of the superficial veins is to be noted—normally
filled veins or pale/discoloured/guttered veins as seen
in ischaemic limb.
Capillary filling time: Initially elevated limbs are made
to hang down the bed. Limb will remain normal and
pink in elevated as well as in dependent position
because of rapid capillary filling time. In ischaemia,
limb initially becomes pale on elevation and gradually
becomes purple-red and then pink in more than 20
seconds. Purple-pink colour is due to deoxygenated
Examination in Arterial Diseases
https://t.me/med1917
blood. Prolonged capillary filling time signifies severe
ischaemia.
Venous refilling time: Elevated limb when laid
horizontal on the bed venous refilling occurs normally
within 5 seconds. It is delayed in ischaemic limb.
Palpation
Temperature of the skin is an important factor in
ischaemic limb. Up to which extent the limb is cold
and proximally where exactly limb/part become
warmer should be assessed. Level of temperature
change from distal colder to proximal warmer area
is important for eventual assessment of level
amputation if needed.
Tenderness— Site/extent/severity should be assessed.
Gangrenous area to be palpated for extent/whether
it is dry and shriveled or whether it is wet and oedematous. Presence or absence of crepitus in gangrenous
area should be checked (Figs 5.7A and B).
Limb above the gangrenous area should be palpated.
115
Capillary refilling: Tip of the nail or pulp of the finger
or toe is pressed to blanch it and pressure is released
(in 2 seconds) to make it pink again. Time taken for
blanched area to turn pink is capillary refilling time.
It is prolonged in ischaemic limb.
Harvey’ s venous refilling test: Two fingers are placed
over the vein and pressure is applied over it. Proximal
finger is moved for about 5 cm proximally without
releasing the pressure. Vein between the fingers gets
emptied completely and becomes flat. Distal finger
is now released to see the flow of the blood and its
refilling is observed, whether good or poor. It is poor
in ischaemic limb.
Elevated arm stress test (EAST): Both shoulders are
abducted 90 degrees with arms fully externally rotated.
Patient will open and close the hands rapidly for 5
minutes. Normal individual can do this without any
discomfort and pain. Patient with thoracic outlet
syndrome develops pain, fatigue, paraesthesia of
forearm with tingling and numbness of fingers. Patient
will not be able to continue the test for 5 minutes.
This test can also differentiate thoracic outlet syndrome
from cervical disc prolapse disease.
A
B
Figs 5.7A and B: Ischaemic features seen in both upper
and lower limbs and also gangrenes in upper and lower
limb in different patients.
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SRB’s Clinical Surgery
Roos test: Patient is asked to elevate and abduct the
shoulders 90 degrees along with external rotation of
arms and keep it for 5 minutes. Patient feels fatigue
on the diseased side.
Costoclavicular compression manoeuvre: While
palpating the radial pulse of the patient he is asked
to move his shoulder backwards and downwards
(exaggerated military position) which may cause
absence/feeble radial pulse and a bruit may be heard
while auscultating the supraclavicular region. This is
due to compression of subclavian artery between
clavicle and first rib.
Hyperabduction manoeuvre (Halsted test): While
palpating the radial pulse, arm on the diseased side is
passively hyperabducted causing feeble or absence of
radial pulse. This is due to compression of artery by
pectoralis minor tendon (pectoralis minor syndrome).
An axillary bruit may be heard on auscultation.
Adson’ s test: While palpating the radial pulse on the
affected side of the patient, patient is asked to take
deep breath and turn his neck/head towards the same
side so as to compress the thoracoaxillary channel.
Adson’s test is said to be positive when pulse becomes
feeble or absent as in thoracic outlet syndrome/scalenus
anticus syndrome. While taking deep breath thoracic
cage moves upwards and narrows the space aggravating the compression of subclavian artery by scalenus
anterior muscle. Contraction of scalenus anterior
further aggravates the feature (by turning neck towards
same side) (Figs 5.8A and B).
Branham’ s/Nicoladoni’s sign: In arteriovenous fistula
when pressure is applied over the artery proximal to
the fistula, there will be reduction in pulse rate and
size of the swelling with disappearance of bruit and
pulse pressure becoming normal.
Allen’ s test: It is used in hand to find out the patency
of radial and ulnar arteries. Both radial and ulnar
arteries of the patient is felt and pressed firmly at the
wrist. Patient clinches his hand firmly (often repeated
clinching) and holds it tightly. After 1 minute clinch
is released to open the palm of the hand which looks
pale. Pressure on radial artery in the wrist is released
to see area of distribution of the radial artery. Normally
it becomes flushed with pink colour. If there is block
in radial artery, the area will remain white. Test is
A
B
Figs 5.8A and B: Adson’s test.
repeated again (Figs 5.9A to D). This time pressure
on the ulnar artery is released to check the patency
of ulnar artery. Area will be pale and blanched after
releasing in case of ulnar artery block. Otherwise it
becomes pink after release in normal individual.
Cold and warm water test: It is commonly done to
confirm Raynaud’s phenomena. Patient is asked to
dip hands in cold water to precipitate the vasospasm
and Raynaud’s syndrome.
Crossed leg test (Fuchsig’s test): Patient is asked to
sit with the legs crossed one above the other so that
the popliteal fossa of one leg will lie against the knee
of other leg. Oscillatory movements of foot can be
observed synchronous with the popliteal artery
pulsation. If the popliteal artery is blocked oscillatory
movements will be absent (Figs 5.10A and B).
Disappearing pulse syndrome: Exercise the limb after
feeling the pulse. Pulse will disappear once patient
develops claudication. It is because of vasodilatation
and increased vascular space that occurs due to exercise
Examination in Arterial Diseases
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A B
117
C
Figs 5.9A to D: Allen’s test.
A
Figs 5.10A and B: Cross leg test—checking oscillatory
B
movements.
D
wherein arterial tension can not be kept adequately
and so results in disappearance of pulse (unmasking
the arterial obstruction).
Buerger’s postural test: Patient lying down on his
back is asked to raise the leg forward for two minutes.
In normal individuals limb (plantar aspect of foot)
remains pink even after raising to 90 degrees. Ischaemic
limb, when elevated shows marked pallor and empty
veins. The angle in which pallor develops is called
as Buerger’ s angle of vascular insufficiency. Less than
30 degrees angle indicates severe ischaemia. Ischaemic
height of the heel in relation to the sternal angle where
pallor develops in heel signifies the severity of the
disease. This height in centimeter is equal to the arterial
pressure in the foot in mm Hg. After that, patient is
asked to keep the legs below the bed to fill the vessels.
Time taken for the leg to become pink is capillary
filling time. Filling time more than 30 seconds suggests
severe ischaemia in the limb. In ischaemic limb, after
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lowering from elevated position, cyanotic hue appears
on the dorsum of foot (in 3 minutes of lowering).
Guttering of vein is observed in ischaemic limb while
raising the leg for 15° due to complete collapse of
the veins whereas in normal individual veins are only
partially collapsed while raising the leg.
Reactive hyperaemia time test: Inflate the sphygmomanometer cuff around the limb up to 250 mm Hg
for 5 minutes till significant pallor appears. Release
and assess the time of appearing of red flush in skin
which signifies the reactive hyperaemia time. Normal
time is 2 seconds. It is delayed in ischaemia.
Palpate the limb for crepitus (in gas gangrene);
tenderness along the line of vessel (thrombosis);
oedema, etc.
Palpation of Blood Vessels
Dorsalis pedis artery is felt just lateral to the extensor
hallucis longus tendon at the proximal end of first
web space, against the navicular and middle cuneiform
bones. It is absent in 10% cases (Fig. 5.11).
Fig. 5.12: Palpation of posterior tibial artery.
Anterior tibial artery is felt anteriorly in the midway
between the two malleoli against the lower end of
tibia just above the ankle joint lateral to extensor
hallucis longus tendon (Figs 5.13A and B).
Popliteal artery is difficult to feel. It is palpated better
(most reliable method) in prone position with knee
flexed about 130 degrees (from straight knee 180° to
130°) to relax popliteal fascia. It is felt in the lower part
of the fossa over the flat posterior surface of upper end
of tibia. Artery is not felt in upper end of the fossa, as
there is no bony area in intercondylar region. It can also
be felt in supine position with knee flexed to 130
degrees (most convenient method) to relax the popliteal
fossa so that pulsation can be felt over the upper part
against tibial condyles (Figs 5.14A and B).
Fig. 5.11: Palpation of dorsalis pedis artery pulsation.
Posterior tibial artery is felt against the calcaneum
just behind the medial malleolus midway between it
and tendoAchilles (Fig. 5.12).
Femoral artery in the groin is felt just below the
inguinal ligament, midway between anterior superior
iliac spine and pubic symphysis (mid-inguinal point).
Often hip has to be flexed for about 10-15 degree
to feel it properly (Fig. 5.15).
Radial artery is felt at the wrist on the lateral aspect
against lower end of the front of radius (Fig. 5.16).
Ulnar artery is felt at the wrist on the medial aspect
against lower end of the front of ulna (Fig. 5.17).
Brachial artery is felt in front of the elbow just medial
to biceps brachii tendon (Fig. 5.18).
Axillary artery is felt on lateral aspect of the axilla
against upper end of the shaft of humerus with raised
and elevated arm (Fig. 5.19).
Examination in Arterial Diseases
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A
A
119
B
Figs 5.13A and B: Palpation of anterior tibial artery.
Subclavian artery is felt against first rib just above
the middle of the clavicle in supraclavicular fossa while
patient is lifting the shoulder to relax deep fascia (Fig.
5.20).
Common carotid artery is felt medial to sternomastoid
muscle at the level of thyroid cartilage against carotid
tubercle (Chassaigne tubercle) of transverse process
of 6th cervical vertebra (in carotid triangle) (Fig. 5.21).
Facial artery is felt against body of mandible at the
insertion of masseter (Fig. 5.22).
Superficial temporal artery is felt just in front of the
tragus of the ear against zygomatic bone (Fig. 5.23).
B
Figs 5.14A and B: Palpation of popliteal artery both in
supine and prone positions. Prone position is always better.
Fig. 5.15: Palpation of femoral artery.
Fig. 5.16: Palpation of radial artery.
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Fig. 5.17: Palpation of ulnar artery.
Fig. 5.20: Palpation of subclavian artery.
Fig. 5.18: Palpation of brachial artery.
Fig. 5.19: Palpation of axillary artery.
Condition of the vessel wall, thrill and any tenderness
on the artery should be mentioned.
Ulcer if present should be examined for different features like tenderness/mobility/fixity/base induration.
Assessment of limb muscle wasting is important to
find out the severity of ischaemia. It is done by inspecting the muscle bulk; prominent bony prominences;
by measurement of the limb girth (circumference is
measured using a tape, 15 cm away from the bony
point) (Figs 5.24A and B).
Fig. 5.21: Palpation of common carotid artery.
Fig. 5.22: Palpation of facial artery.
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