Own the … Vascular Examination

Didn’t add videos because you don’t really need them to do this and all the ones on the net are a tad too brief anyway. Also, apparently there’s a few ways of doing the Trendelenburg test (seriously, how many things are named after this guy) so get your reg to show you.

  • History
    • Claudication
      • Factors in favour of neurogenic claudication are variabale caludication distance, aggravation with bending over, requiring sitting down or leaning on trolley to relieve pain and immediate relief once in a good posture
    • Rest pain – exacerbated by lying down or elevation of the foot, relieved by hanging the foot out of bed
    • Acute arterial occlusion – 6 Ps – pain, pallor, paraesthesia, ‘paralysis’, pulses absent, perishing cold
    • focal neurology, amaurosis fugax
  • Inspection
    • Inspect while erect for varicosities, scars (vein harvests) and changes indicative of diabetic foot (pes planus, clawing, hallux valgus etc.)
    • Skin changes
      • Lipodermatosclerosis – thickening, pigmentation, induration and inflammation of skin
      • Pigmentation may be a sequela of cellulitis – pigmentation without fibrosis is not venous disease. Pigmentation in the forefoot is also not typical of venous disease
    • Colour changes
      • Rubor is due to venous pooling
      • Hemosiderin deposition leads to brownish discolouration
      • Acute arterial occlusion leads to pallor
    • Ulceration – inspect between the webs of the toes
      • Venous ulcers – garter area, irregular margin, pale neo-epithelium, pink base of granulation, warm and oedematous surroundings
      • Arterial ulcers – regular margin, punched out appearance, cold surroundings, pain (pain very specific for arterial aetiology)
      • Diabetic ulcers –painless with reduced sensation in surrounding skin
    • Gangrene
  • Palpation
    • Capillary refill
    • Temperature
    • Tenderness
    • Tenseness
    • Pulses; if unsure if its a faint pulse of your own digital pulses, simultaneously palpate your own radial pulse and look for asynchrony
      • Radial, radial-radial delay
      • Brachials
      • Carotids
      • Abdominal aorta
      • Femorals
      • Popliteal
      • Posterior tibial
      • Dorsalis pedis
  • Auscultation
    • Subclavian
    • Carotids
    • Renal bruits
    • Aortic
    • Femoral
  • Special test
    • Buerger’s for arterial insufficiency – elevate the limb to 45 degrees for 30 seconds, then drop it into a dependent position. Poor arterial pressure is insufficient to overcome drainage to the heart causing pallor. Plethora on assuming the dependent position is due to reactive hyperaemia. Guttering of the veins when elevated is indicative of poor arterial driving pressure.
    • ABPI – use Doppler to measure pressures – remarkably difficult to auscultate DP or PT pulses. Severe arterial disease <0.5 < moderate <0.8 < mild < 0.9 <normal <1.2 < calcification
    •  Trendelenburg test
    • Neurological examination
  • Supplementary + random things noted down during registrar teaching
    • Sexual impotence +buttock claudication = Leriche’s syndrome
    • The 4 main categories of all PAD patients are caludicants (40%), critical limb ischaemics (rest pain +/- ulcers <5%), asymptomatics (40%) and atypical presentations (15%)
    • There is an equal risk of death of patients with PAD as those with CAD which is around 20% mortality in five years
    • There is no evidence showing benefit of dual antiplatelet therapy except for stent implantation
    • The 24 month mortality of critical limb ischaemia is 50%; 25% will lose one or both legs and 25% will live with both legs
    • Surgery for PAD is done to improve symptoms, not mortality as in all PAD patients, intervention has no significant effect on mortality
    • With patients, 1/3 get better, 1/3 stay the same, 1/3 get worse
    • Symptomatic patients with carotid stenosis >50% should be offered an operation within 3 weeks due to the high risk of recurrent strokes exceeding the risk of peri-operative stroking out (2-4%)
    • The evidence for operation in asymptomatic carotid stenosis is not great, but around 80-90% is a reasonable indication for intervention
    • In general endovascular techniques are inferior to carotid endarterectomy in terms of peri-operative complications
    • Women seem to do worse than men with carotid procedures
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