Peripheral arterial disease physical examination

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Case #1
AHA/ACC Guidelines on Management of Lower Extremity PAD
Guidelines for Clinical Assessment of Lower Extremity PAD
Guidelines for Diagnostic Testing for suspected PAD
Guidelines for Screening for Atherosclerotic Disease in Other Vascular Beds in patients with Lower Extremity PAD
Guidelines for Medical Therapy for Lower Extremity PAD
Guidelines for Structured Exercise Therapy for Lower Extremity PAD
Guidelines for Minimizing Tissue Loss in Lower Extremity PAD
Guidelines for Revascularization of Claudication in Lower Extremity PAD
Guidelines for Management of CLI in Lower Extremity PAD
Guidelines for Management of Acute Limb Ischemial in Lower Extremity PAD
Guidelines for Longitudinal Follow-up for Lower Extremity PAD
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Vishnu Vardhan Serla M.B.B.S. [3] Kiran Singh, M.D. [4]

Overview

The patient's lower legs and feet should be examined with shoes and socks off, with attention to pulses, hair loss, skin color, and trophic skin changes. Patients with PAD might have cyanosis, atrophic changes like loss of hair, shiny skin, decreased temperature, decreased pulse or redness when limb is returned to a dependent position. The location of the symptoms depends on the nature of the involved arteries.

Physical Examination

Vitals

• The pulses are usually decreased or absent.
  • The pulses at the brachial, radial, ulnar, femoral, popliteal, dorsalis pedis, and posterior tibial sites are palpated.
  • Performance of allen’s test when knowledge of hand perfusion is needed.
• Pulse intensity should be recorded numerically:
  • 0: Absent
  • 1: Diminished
  • 2: Normal
  • 3: Bounding
• The carotid artery pulse should be palpated and the carotid upstroke and amplitude should be determined.
• Carotid bruits might be detected.
• Blood pressure is measured in both arm and the arms are examined for any inter arm asymmetry.

Skin

• Pallor of feet with elevation
• Signs of chronic ischemia:
  • Hair loss, thickened nails, trophic sin changes hypertrophic nails, smooth and shiny skin, coolness, pallor or cyanosis.
• Dependent rubor

Auscultation

• Bruits can be heard over the sites of arterial narrowing.
• Auscultation of the abdomen and flank for bruits.
• Auscultation of both femoral arteries for the presence of bruits.

Extremities

• Muscle atrophy
• Critical limb ischemia is defined as limb pain that occurs at rest or impending limb loss that is caused by severe compromise of blood flow to the affected extremity. The term “critical limb ischemia” should be used for all patients with chronic ischemic rest pain, ulcers, or gangrene attributable to objectively proven arterial occlusive disease. The term CLI implies chronicity and is to be distinguished from acute limb ischemia.
• Acute limb ischemia arises when a rapid or sudden decrease in limb perfusion threatens tissue viability. This form of CLI may be the first manifestation of arterial disease in a previously asymptomatic patient or may occur as an acute event that causes symptomatic deterioration in a patient with antecedent lower extremity PAD and intermittent claudication. Although the progression of PAD from intermittent claudication to CLI may occur gradually, it may also reflect the cumulative effect of multiple acute local thrombotic events that progressively increase the intensity of ischemia.

Peripheral Vascular Disease of the Hand: Advanced disease with gangrene of several digits.
(Image courtesy of Charlie Goldberg, M.D.)

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  Peripheral occlusive arterial disease. With permission from Dermatology Atlas.

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  Peripheral occlusive arterial disease. With permission from Dermatology Atlas.

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  Peripheral occlusive arterial disease. With permission from Dermatology Atlas.

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  Peripheral occlusive arterial disease. With permission from Dermatology Atlas.

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  Peripheral occlusive arterial disease. With permission from Dermatology Atlas.

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  Peripheral occlusive arterial disease. With permission from Dermatology Atlas.

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  Peripheral occlusive arterial disease. With permission from Dermatology Atlas.

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  Peripheral occlusive arterial disease. With permission from Dermatology Atlas.

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  Peripheral occlusive arterial disease. With permission from Dermatology Atlas.

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  Peripheral occlusive arterial disease. With permission from Dermatology Atlas.

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  Peripheral occlusive arterial disease. With permission from Dermatology Atlas.

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  Peripheral occlusive arterial disease. With permission from Dermatology Atlas.

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  Peripheral occlusive arterial disease. With permission from Dermatology Atlas.

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  Peripheral occlusive arterial disease. With permission from Dermatology Atlas.

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  Peripheral occlusive arterial disease. With permission from Dermatology Atlas.

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  Peripheral occlusive arterial disease. With permission from Dermatology Atlas.

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  Peripheral occlusive arterial disease. With permission from Dermatology Atlas.

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  Peripheral occlusive arterial disease. With permission from Dermatology Atlas.

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  Peripheral occlusive arterial disease. With permission from Dermatology Atlas.

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  Peripheral occlusive arterial disease. With permission from Dermatology Atlas.

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  Peripheral occlusive arterial disease. With permission from Dermatology Atlas.

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  Peripheral occlusive arterial disease. With permission from Dermatology Atlas.

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  Peripheral occlusive arterial disease. With permission from Dermatology Atlas.

Management of Patients With Peripheral Artery Disease (Compilation of 2005 and 2011 ACCF/AHA Guideline Recommendations) : A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines

Clinical Presentation in Asymptomatic PAD Patients (DO NOT EDIT)

Class I

"1. A history of walking impairment, claudication, ischemic rest pain, and/or nonhealing wounds is recommended as a required component of a standard ROS for adults 50 years and older who have atherosclerosis risk factors and for adults 70 years and older. (Level of Evidence: C)"

"2. Individuals with asymptomatic lower extremity PAD should be identified by examination and/or measurement of the ABI so that therapeutic interventions known to diminish their increased risk of MI, stroke, and death may be offered. (Level of Evidence: B)"

"3. Smoking cessation, lipid lowering, and diabetes and hypertension treatment according to current national treatment guidelines are recommended for individuals with asymptomatic lower extremity PAD. (Level of Evidence: B)"

"4. Antiplatelet therapy is indicated for individuals with asymptomatic lower extremity PAD to reduce the risk of adverse cardiovascular ischemic events. (Level of Evidence: C)"

Class IIa

"1. An exercise ABI measurement can be useful to diagnose lower extremity PAD in individuals who are at risk for lower extremity PAD who have a normal ABI (0.91 to 1.30), are without classic claudication symptoms, and have no other clinical evidence of atherosclerosis. (Level of Evidence: C)"

"2. A toe-brachial index or pulse volume recording measurement can be useful to diagnose lower extremity PAD in individuals who are at risk for lower extremity PAD who have an ABI greater than 1.30 and no other clinical evidence of atherosclerosis. (Level of Evidence: C)"

Class IIb

"1. Angiotensin-converting enzyme (ACE) inhibition may be considered for individuals with asymptomatic lower extremity PAD for cardiovascular risk reduction. (Level of Evidence: C)"

Critical Limb Ischemia in PAD Patients (DO NOT EDIT)

Class I

"1. Patients with CLI should undergo expedited evaluation and treatment of factors that are known to increase the risk of amputation. (Level of Evidence: C)"

"2. Patients with CLI in whom open surgical repair is anticipated should undergo assessment of cardiovascular risk. (Level of Evidence: B)"

"3. Patients with a prior history of CLI or who have undergone successful treatment for CLI should be evaluated at least twice annually by a vascular specialist owing to the relatively high incidence of recurrence. (Level of Evidence: C)"

"4. Patients at risk of CLI (ABI less than 0.4 in a nondiabetic individual, or any diabetic individual with known lower extremity PAD) should undergo regular inspection of the feet to detect objective signs of CLI. (Level of Evidence: B)"

"5. The feet should be examined directly, with shoes and socks removed, at regular intervals after successful treatment of CLI. (Level of Evidence: C)"

"6. Patients with CLI and features to suggest atheroembolization should be evaluated for aneurysmal disease (e.g., abdominal aortic, popliteal, or common femoral aneurysms). (Level of Evidence: B)"

"7. Systemic antibiotics should be initiated promptly in patients with CLI, skin ulcerations, and evidence of limb infection. (Level of Evidence: B)"

"8. Patients with CLI and skin breakdown should be referred to healthcare providers with specialized expertise in wound care. (Level of Evidence: B)"

"9. Patients at risk for CLI (those with diabetes, neuropathy, chronic renal failure, or infection) who develop acute limb symptoms represent potential vascular emergencies and should be assessed immediately and treated by a specialist competent in treating vascular disease. (Level of Evidence: C)"

"10. Patients at risk for or who have been treated for CLI should receive verbal and written instructions regarding self-surveillance for potential recurrence. (Level of Evidence: C)"

Acute Limb Ischemia in PAD Patients (DO NOT EDIT)

Class I

"1. Patients with acute limb ischemia and a salvageable extremity should undergo an emergent evaluation that defines the anatomic level of occlusion and that leads to prompt endovascular or surgical revascularization. (Level of Evidence: B)"

Class III

"1. Patients with acute limb ischemia and a nonviable extremity should not undergo an evaluation to define vascular anatomy or efforts to attempt revascularization. (Level of Evidence: B)"

References

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