Slide 1
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Vascular
Assessment
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With and
Without
Equipment
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Slide 2
Without Equipment
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Look
Listen
Touch
Feel
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Slide 3
Look
• Skin
– Colour
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• Dependent
• Horizontal
– Skin texture
– Ulcers / pre-ulcers
– Oedema
• Hair + Nails
• Smoker?
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Slide 4
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Skin quality
• Colour
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– White
– Red
– Blue / cyanotic
• Integrity
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Loss of hair
Thin skin
Reduced nail growth
Heel fissures
Ulcers / pre-ulcers
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• Bony prominences
• Areas under pressure
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Slide 5
Listen = c/o
•
•
•
•
•
Cold feet, even in bed
Claudication
Rest pain
Numbness
Paraesthesia
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Slide 6
Touch
• Skin temperature
– Proximal to distal
– Left + right
– Use back of your hand
– Use your inner forearm
• Tissue texture
– Loss of fibrofatty padding
– Atrophy of pulps
– Oedema
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Slide 7
Testing for Ischaemia:
Manually Examine the Legs / Feet
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• Pedal Pulses
– Palpate Popliteal; DP; TP; Peroneal
– Rate? Regularity? Robustness?
• Temperature gradient
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– Sudden changes (hot / cold)
• Capillary filling time
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Slide 8
Feel
• Palpate pulses
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– Dorsalis pedis
– Tibialis posterior
– Peroneal
– Popliteal
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• Use 2 fingers
• Compare limbs
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Slide 9
Palpating Limb Pulses
TP
DP
Popliteal

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Don’t forget the
peroneal!
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Slide 10
FATAL
•
•
•
•
•
Feel
= palpate pulses
Ask = about symptoms
Touch
= tissue temperature and texture
and
Listen
= to what the patient says
(the words between the words)
It is FATAL to miss any of these actions!
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Slide 11
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Now add in a bit of
equipment…..
To confirm your impressions, so far
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Slide 12
Skin temperature
• Normal ~ 330C
• Cooler at toes ~ 310C
• Dependent on
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Recent activity
Weather
Season
Shoe / sock type
Vascular status
• Ischaemia = cool / cold
• Venous compromise = warmer
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Slide 13
The Doppler
• Coupling Gel is essential
• The Probe is angled at approx. 45o
TOWARDS the direction of blood
flow
• Note
– RATE (pulse),
– VOLUME (flow) , and
– SOUND QUALITY (phase)
• of the audible Doppler sounds
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Slide 14
Arterial Doppler Sounds
The pulse imparted by cardiac contraction (heart beat)
is not heard as a single sound on Doppler
ultrasonography
Doppler sounds indicate the health of the
caridovascular system
• Phase reflects elasticity of artery wall
• Volume of sound reflects flow
• Regularity reflects heart function
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Slide 15
Doppler sounds - Phases
• Triphasic sound (Saus-ag-es)
– Good arterial elasticity
• Biphasic sound (Hell-o)
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– Adequate arterial elasticity
• Monophasic sound (Whoosh)
– Minimal / no arterial elasticity
• No sound
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– Arterial obstruction
– Incorrect placement of Doppler probe
• Squeaks, barks and grunts
– Bruits
– Arterial stenosis and / or turbulent flow
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Slide 16
Doppler sounds - Volume
• Loud
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–
Autonomic neuropathy (DM)
Increased flow through deep vessels
Minimal flow through capillaries
Shunts open
• Moderate
– Normal
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• Quiet
– Reduced flow
– Arterial compromise
• None
– Arterial obstruction
– Check position of Doppler probe
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Slide 17
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Volume: reflects the amount of blood flowing though the
artery
• Strength of sound
– Loud – associated with arteriovenous shunting
– Normal
– Quiet – reflects reduced blood flow
• Also depends on
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– clinician proficiency
– peripheral oedema
NB: All Doppler sounds are better
heard through earphones
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Slide 18
Doppler sounds - Regularity
• Beats per minute
– ~60-75 at rest
– Increased (exercise, AF)
– Decreased (reduced cardiac function)
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• Beat pattern
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Regular
Normal cardiac function
Regularly irregular
Altered cardiac function
Not necessarily worrying but of note to GP
Irregularly irregular
Compromised cardiac function
AF
Note to GP
May need medication / pacemaker
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Slide 19
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Venous Doppler Sounds
• Normal
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– Whaa-aaa (Wind
blowing down the
chimney)
– May ‘pulse’ as vein lies
close to artery within the
neurovascular bundle
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• Absent
– Indicates venous
thrombosis
– Calf squeeze test +ve
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Slide 20
The Ankle Brachial Pressure Index
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Best to use an old-fashioned Sphygmomanometer
•
Patient supine on couch
•
ANKLE SYSTOLIC PRESSURE
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•
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Put BP cuff on lower leg just above the ankle
Locate DP pulse with Doppler
Inflate BP cuff until Doppler sound disappears
Deflate BP cuff slowly and note the pressure reading (in
mmHg) when first sound (i.e. Systolic BP) is heard
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BRACHIAL SYSTOLIC PRESSURE
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Put BP cuff on upper arm just above elbow
Locate brachial pulse with Doppler
Inflate BP cuff until Doppler sound disappears
Deflate BP cuff slowly and note the pressure reading (in
mmHg) when first sound (i.e.: Systolic BP) is heard
ABPI = A/B
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Slide 21
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Doppler Examination: ABI
• A: The Doppler is used to record pedal systolic
pressures
DP
• B: The Doppler is used to record brachial systolic
pressure
Right
arm
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TP
Left
arm
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Slide 22
Calculation of ABI
The ankle / brachial ratio of systolic
pressures is calculated as the ratio of
– Systolic pressure at Ankle (TP or DP)
– Highest systolic pressure arm (Brachialis)
• i.e.: A/B
• Normal range = 0.9 – 1.1
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– Ischaemia = < 0.7
• reduced flow to foot
– Ischaemia = > 1.3
• incompressible foot artery
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Slide 23
Absolute toe pressure
Systolic pressure recorded at hallux pulp
or hallux digital artery of supine patient
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Gives strong indicator of lesion healing potential
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Slide 24
Doppler Examination: TBPI (1)
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Slide 25
Doppler Examination: TBPI (2)
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Slide 26
TPBI
• Normal, i.e.: no distal arterial disease
• = >0.7
• Borderline ischaemia, i.e.: Compromised
arterial supply to distal foot
• = 0.64 – 0.7
• Distal arterial disease
• = <0.64
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Slide 27
Measurement of Blood Pressure
• Inflate the cuff above systolic
pressure
• Deflate the cuff slowly
• Note the pressure (in mm Hg)
when the first sound is heard
– STYSTOLIC PRESSURE
• Note the pressure (in mm Hg)
when the last sound is heard
– DIASTOLIC PRESSURE
• BP = Systolic / Diastolic
• 120/80
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Slide 28
Automatic Sphygmomanometer
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Inflate cuff
Records systolic BP
Records diastolic BP
Records pulse rate
Memory function
• All at the touch of a button!
• Difficult to use on lower leg
• Difficult to get accurate
ankle systolic BP
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Slide 29
Portable (Finger) Pulse Oximeter
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Pulse rate
Blood oxygenation (SpO2)
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Slide 30
Intermittent Claudication
• Claudication distance
– How far can the patient walk before they develop limb
pain?
– IC is analogous to angina of effort
• Reported by patient
• Revealed by treadmill / stairs walking
– Increased demand for oxygenated blood by exercising
muscle cannot be supplied by reduced arterial flow
– Reliably causes discomfort or frank pain
– Affects MLA, calf, thigh or buttocks
• Refer
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Slide 31
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Rest Pain
• Rest pain occurs in a limb with severe
ischaemia
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– + Other signs associated with limb ischaemia
• Pain occurs in bed or with limb elevation
– No gravity to assist supply to foot
– Warm environment in bed increases metabolic
rate of foot / limb
• Symptoms eased by
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– Standing up
– Cooling limb
• Patients must be referred
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– Do not confuse with night cramps
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Slide 32
Effects of limb positional change
•
Buerger’s test – does arterial blood flow uphill?
– Patient supine
– Elevate lower leg from horizontal
– Note angle of limb when MLA blanches
• NB: 1 hour on the clock face = 30o
– Lower leg to floor
– Time in secs for colour return
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Slide 33
Buerger’s Test
Supine patient
• Elevate limb
• Note limb angle when MLA blanches
(NB: 1 division on a standard clock face
= 300)
• Lower limb / foot to floor
• Note time taken (in secs) for normal
colour to return to foot
• Note colour changes (pallor, rubeosis,
cyanosis)
• Note that veins should fill from distal
to proximal
– from proximal to distal =
incompetent vein valves
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Buerger’s Angle = 0o
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Slide 34
Allen’s Test
• Adapted from hand radial and ulnar artery
assessment
– If one artery is blocked, blood should still enter the
hand by the other artery
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• Used to establish patency of foot arteries
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Elevate limb from horizontal to pallor
Block DP pulse with fingers
Lower leg to vertical
Observe colour return via posterior tibial artery
Elevate limb from horizontal to pallor
Block TP pulse with fingers
Lower leg to vertical
Observe colour return via dorsalis pedis artery
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Slide 35
Toe Pole Test: For measurement of ankle
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pressures in patients with calcified vessels
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•
The Doppler probe is placed over a patent
pedal artery
The foot is raised against a pole that is
calibrated in mm Hg.
The point at which the pedal signal
disappears is taken as the ankle pressure
Alternatively:
The Doppler probe is placed over a patent
pedal artery and the foot raised against a
pole that is calibrated in cm
The height (h) in cm at which the pedal
Doppler signal disappears is noted
Ankle systolic pressure in mm Hg is
calculated as h (in cm) x 7.35
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Slide 36
Segmental Volume Plethysmography 1
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Slide 37
Segmental Volume Plethysmography 2
• Pulse volume varies in relation to the
severity of peripheral vascular disease
• Normal arteries show dichrotic notch
• Mild vascular disease:
– Trace shows no dichrotic notch
• Moderate vessel disease:
– Trace shows equal arms
• Severe disease:
– Amplitude of trace is reduced
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Slide 38
5 minute reactive hyperaemia test
• Supine patient; knees flexed
– ankle systolic BP noted
• Limb elevated to 300 above horizontal
– Ankle repeatedly flexed to drain venous blood
from limb
– Cuff inflated to ASBP+100mmHg (foot goes
white)
• Limb lowered to horizontal
– BP cuff released after 5 mins
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• Time taken to colour return and maximum
tissue perfusion noted
– < 1 min + uniform colour = normal
– 2 mins + red toes = vasospastic disease
– > 2 mins + pale toes = limb ischaemia
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Slide 39
Obstruction of capillary flow
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Capillary refill time
• Thumb pressure
• Record time (secs)
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– Instantaneous
– Slow (2-3 secs)
– >3secs worrying
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• Weather dependent
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Slide 40
Oedema and poor arterial perfusion
• Reduced arterial flow may
cause oedema
– Rest pain prevents bed rest
– Ischaemia is increased by pressure
of retained fluid
• Indicators of ischaemia:
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Oedema + pallor
Oedema + cyanosis
Oedema + tissue atrophy
Oedema + cold and RED
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Slide 41
Venous function
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Varicose veins
Varicose eczema
Lipodermatosclerosis
Varicose ulceration
Oedema
– Pitting
– Woody
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Slide 42
Mixed vascular problems
= At risk limb
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• Arterial compromise
• Venous incompetence
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Slide 43
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SUMMARY
Vascular Examination
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Slide 44
Points to note:
• From visual examination
• From palpation
• From instrumentation
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Slide 45
From visual examination
• Skin colour
• Skin temperature
• Skin texture
– Nail quality
– Presence / absence of hairs
• Skin integrity
– Ulcers; Pre-ulcers
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• Soft tissue integrity
– Soft tissue atrophy
– Presence / absence oedema
• Pitting / woody
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Slide 46
From palpation
Pulses
• Regularity
• Strength
• Ease of palpation
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Presence / absence oedema
• Pitting / woody
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Slide 47
From tests
• Capillary return
• Buerger’s angle
• Vascular return time
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Slide 48
Using instrumentation
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Doppler sounds
ABPI
TBPI
Reactive hyperaemia test
BP
Duplex Scans
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Slide 49
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Thank you for your kind attention!
www.DrJeanMooney.com
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