Vascular Exam
Laurie Kuestner MD
Iowa Heart Center
Vascular Diseases Covered
- Peripheral arterial disease
- Acute limb ischemia
- Pseudoaneurysm/arteriovenous fistula
- Popliteal aneurysmal disease
- Aortic aneurysmal disease
- Mesenteric atherosclerosis
- Renal atherosclerosis
- Carotid atherosclerosis
- Subclavian atherosclerosis
- DVT
- Peripheral venous insufficiency
- lymphedema
Arterial
Venous
Peripheral Arterial Disease
- Lifetime tobacco exposure
- Diabetes mellitus
- Claudication
- Rest Pain
- Pedal ulceration/gangrene
Hgb A1c and Lower Extremity Amputation Risk in Low-Income
Patient with Diabetes
| <6% | 6 - 6.9 | 7 - 7.9 | 8 - 8.9 | 9 - 9.9 | > 10% | |
|---|---|---|---|---|---|---|
| Black | 1.00 | 1.73 | 1.65 | 1.96 | 3.02 | 3.3 |
| White | 1.00 | 1.16 | 2.28 | 2.38 | 2.99 | 3.25 |
Diabetes Care 2013 Nov:36:3591-3598
PAD
Ambulatory Status
Any limitations walking ?
When is the last time you went to a park and walked a 3 mile loop ?
Rutherford Classification of PAD
| Grade | Category | Patient Presentation |
|---|---|---|
| 0 | 0 | Asymptomatic |
| I | 1 | Mild claudication |
| I | 2 | Moderate claudication |
| I | 3 | Severe claudication |
| II | 4 | Ischemic rest pain |
| II | 5 | Minor tissue loss |
| III | 6 | Major tissue loss |
PAD exam
- ABI
- bilateral femoral pulses
- bilateral popliteal pulses
- bilateral posterior tibial pulses
- bilateral AT or DP pulses
- pedal ulceration or gangrene
- elevation pallor
- dependent rubor
ABI
| ABI | |
|---|---|
| normal | > 0.9 |
| mild arterial insufficiency | 0.7 - 0.9 |
| moderate arterial insufficiency | 0.5 -0.69 |
| severe arterial insufficiency | < 0.5 |
ABI = highest ankle pressure/
highest brachial pressure
femoral
posterior tibial
dorsalis pedis
palpation exam
normal 2+
diminished 1+
absent
bounding 3+
popliteal
doppler description
biphasic
monophasic
R PT
palpable 2+
L PT
monophasic
by doppler
Limb threatening Ischemia
Elevation Pallor
Limb threatening Ischemia
Dependent
Rubor
Pedal
Gangrene
Acute Limb Ischemia
- Pain
- Pallor
- Pulselessness
- Paresthesia
- Paralysis
- Poikilothermia
Acute limb ischemia
- atrial fibrillation
- recent arterial access
- claudication
- prior revascularization
Physical exam
- no dopplerable pulses
- pallor
- cool
- cardiac rhythm
- neurologic exam
- (motor or sensory deficits)
Pseudoaneurysm/
Arteriovenous fistula
- recent arterial access
- antiplatelet
- anticoagulant
- access site swelling
- access site pain
- access site ecchymosis
- pulsatile mass
- systolic bruit
Arteriovenous fistula
- palpable thrill
- continuous bruit (holosystolic/diastolic)
Pseudoaneurysm
Popliteal Aneurysm
- history of aortic aneurysm
- claudication
- rest pain
- acute limb ischemia
Physical Exam
- palpation of popliteal fossa
- pedal pulse exam
- ABI
History
Abdominal Aortic Aneurysm
- usually asymptomatic
- male gender
- age >65
- prior smoker
- tall stature
- history of popliteal artery aneurysm
Abdominal Aortic Aneurysm
pulsatile mass in epigastrium
Mesenteric Atherosclerosis
(Intestinal Angina)
- postprandial abdominal pain
- diarrhea
- weight loss
Mesenteric atherosclerosis
- epigastric bruit
- emaciated
Renal atherosclerosis
- malignant hypertension
- multiple anti-hypertensives
Physical exam
- RUQ or LUQ bruit
- significant hypertension
Symptoms
Carotid atherosclerosis
- asymptomatic
- amaurosis fugax
- hemispheric TIA
- prior stroke
Physical Exam
- carotid bruit
- neurological exam
Symptoms
Subclavian atherosclerosis
- asymptomatic
- arm claudication
- vertebrobasilar insufficiency
- LIMA to LAD bypass?
Physical Exam
- > 15 mm Hg gradient between right and left brachial pressures
- brachial and radial pulse exam
- ulnar pulse exam
Symptoms
DVT / PE
- recent immobilization
- trauma
- recent surgery
- family history of DVT
- oral contraceptives
- hypercoagulable state
- acute swelling
- pain
- dyspnea
- pleuritic chest pain
History
Symptoms
- unilateral limb swelling
- limb discoloration
- dyspnea
- hypoxia
- hypotension
DVT / PE
Physical Exam
Peripheral Venous
Insufficiency
- swelling
- pain
- pruritis
- discoloration
- lipodermatosclerosis
- ulceration
- multiparous
- history of DVT
Symptoms
- swelling
- hyperpigmentation
- lipodermatosclerosis
- ulceration
Peripheral Venous
Insufficiency
Physical Exam
Lympedema
- pedal involvement
- swelling
Physical Exam
Lympedema
Physical Exam
- pedal involvement
- swelling
Lympedema
Physical Exam
- pedal involvement
- swelling