Vascular clinical evaluation

History

• Broad categories of complaints:
  • Pain
  • Weakness
  • Neurosensory complaints
    • Warmth
    • Coolness
    • Numbness
    • Hypersensitivity
  • Discolouration
  • Swelling
  • Tissue loss/ulceration
  • Varicosities
• Ask about:
  • Duration of symptoms
  • Progression or changes since initial onset
  • Location
  • Character or quality
  • Extent of functional limitation
  • Precipitating/aggravating
  • Associated signs and symptoms
  • Risk factors

Examination

• Inspection
  • Skin changes - atrophy, cyanosis, pallor, rubor, hair distribution, nail thickening
  • Oedema
  • Tissue loss and ulceration - location, size, depth, cellulitis
  • Ulcers
    • 
    • Apparently, more than 95% of all leg/foot ulcers will fit neatly into a category - arterial, venous, neuropathic
    • Others:
      • Vasculitis - multiple punched out ulcers with inflamed, indurated base, with a biopsy suggesting fat necrosis or chronic panniculitis
      • Hypertensive ulcers - focal infarcts - very painful - located around the malleoli
      • Underlying osteomyelitis
      • Malignant skin lesion
  • Motor function
• Palpation
  • Changes in temperature/sensation - compare with other size
  • Pulses - absent, decreased, normal, prominent (aneurysm)
    • Superficial temporal artery
    • Carotid - mid-neck, anterior to SCM
    • Subclavian - supraclavicular fossa
    • Axillary - either lateral to clavicle in deltopectoral groove, or in the axilla
    • Brachial - ACF
    • Radial - wrist
    • Ulnar - requires firmer palpation
    • Common femoral - mid-inguinal point
    • Popliteal - lateral to popliteal fossa
    • Dorsal pedal - between first and second metatarsals (congenitally absent in 10%)
    • Posterior tibial - hollow posterior to the medial malleolus - gentle pressure
• Auscultation
  • Normal arteries are silent
  • Bruit - turbulent blood flow. Pitch and duration of a systolic bruit are correlated with increasing severity of arterial narrowing, but it's difficult to quantify the degree of narrowing.
  • Bruit in diastole suggests AVF
• Special tests
  • Allen test - occlude radial and ulnar arteries, while the patient opens and closes the hand, making a fist, causing blanching of palmar skin. Either artery can then be released to check collaterals.
  • Homan's sign - passive dorsiflexion of the foot causing calf pain in calf DVT
  • Bancroft sign - tenderness on anteroposterior but not lateral compression of the calf - DVT
  • Lowenberg sign - calf pain a/w inflation of blood pressure cuff
  • Buerger's test - check for elevation pallor - a positive test meaning arterial insufficiency, is when the leg turns pale at 30 degrees for 30 seconds. A 'vascular angle' of <20 degrees indicates severe ischaemia. Then, return the foot to a dependent position and check for rubor of dependency.

Liedo reticularis

Livedo reticularis:

• Macular, violaceous connecting rings forming a net-like pattern
• Secondary to decreased flow leading to hypoxia and collateral formation
• Can be due to PAD, in areas of ischaemia, but more commonly due to vasculitis, calciphylaxis, atheroemboli, hyperviscosity syndromes, endocrine abnormalities, or infection

Review of patients with arterial disease

• Acute arterial occlusion
  • Pain, pallor, pulselessness, paralysis, paraesthesia, poikilothermia
  • Generalised pain, severe and not well-localised
  • Absent motor function - severe limb-threatening ischaemia
  • If embolic, there will not generally be a history of claudication or chronic occlusive arterial disease. There will often be a history of AF or previous embolic event
  • If thrombotic, there Is generally a history claudication or known vascular disease
• Atheroembolism (blue toes syndrome)
  • Ask about progressive renal insufficiency
  • Recent catheter-related procedures, but can also be spontaneous
• Lower extremity claudication
  • Symptoms associated with walking

Venous disease

• Venous obstruction
  • Pain
  • Swelling
  • Phlegmasia alba dolens
    • Pale, white extremity
    • Frequently seen in post-partum period
    • Collateral veins often seen over upper thigh and abdomen
    • Swelling frequently a/w fever, pain in calf/popliteal fossa/groin
    • Homans attributed this to underlying iliofemoral venous thrombosis
    • Absence of bluish discolouration may be due to rapid discolouration of collateral venous flow
  • Phlegmasia cerulea dolens
    • Massively swollen and cyanotic leg
    • Fluid sequestration in the interstitium
    • Won't be able to feel pulses due to oedema
    • Findings c/w compartment syndrome
    • Needs urgent medical and surgical therapy targeted at underlying cause to prevent venous gangrene
    • Should do a Doppler to confirm persisting flow in tibial vessels
• DVT
  • Unilateral swelling, discomfort, sense of fullness or pressure
  • Need to identify whether provoked or non-provoked
  • Look for a difference in calf circumference of 3cm or 2cm in thigh for a high probability of DVT
• Superficial venous insufficiency:
  • Incompetent valves at saphenofemoral or saphenopopliteal junctions, with subsequent loss of valvular function along the great and small saphenous veins respectively
  • Telangiectasias, reticular varicosities, large ropey varicose veins (which can be traced back to the great or small saphenous veins)