14 Vascular (arterial)

Lower limb
Checklist P MP F

Checklist P MP F • Palpates pulses bilaterally: femoral (mid-

inguinal point), popliteal, dorsalis pedis
HELP
(between 1st and 2nd metatarsals) and
H: ‘Hello’ (introduction and gains consent) posterior tibial (half way between tip of heel
E: Exposure (entire leg up to groins) and medial malleolus)
L: Lighting • Comments on rhythm (atrial fibrillation
P: Positions correctly (supine), asks if the patient – increased risk of embolic disease)
is in any pain • If unable to palpate, states intent to use
Washes hands Doppler ultrasonography

Inspection (patient on bed): • Measures Buerger’s angle and performs

Buerger’s test, commenting on reactive
• From end of the bed:
hyperaemia if present (feet become a dusky
• Comfortable, cyanosis, pallor red colour)
• Obvious pathology (amputation, stockings, • Assess for venous guttering (elevate leg to 15
scars) degrees)
• Around the bed (cigarettes, medication Auscultates:
[GTN], walking stick)
• Bruits (abdominal aorta, femoral pulses)
• Skin colour (pallor, cyanosis)
States intention to do the following to complete
• Trophic changes (hair loss, muscle wasting, the examination:
shiny skin)
• Examine remainder of peripheral vascular
• Scars (e.g. vein harvesting) system
• Ulceration (heel, tips of toes, in between toes, • Examine cardiovascular system
lateral malleolus, punched-out, painful, over
• Measure ankle–brachial pressure indexes
pressure points)
(ABPIs) using Doppler assessment
• Gangrene (dry/wet – infected)
• Conduct a neurological assessment of the
• Amputation lower limbs
• Dressings (states would ideally examine • Conduct a musculoskeletal examination
underneath)
Thanks patient
• Stigmata of vascular disease: nicotine staining
Offers to help patient get dressed
(smoking), xanthoma, xanthelasmata
(hypercholesterolaemia), necrobiosis lipoidica Washes hands
(diabetes) Presents findings
Palpation: Offers appropriate differential diagnosis
• Examines abdomen for abdominal aortic Suggests appropriate further investigations and
aneurysm (size) management
• Skin temperature with back of hands OVERALL IMPRESSION:
• Assesses capillary refill in both feet
(<2 seconds)

68
 Examinations: 14 Vascular (arterial) 69

Summary of common conditions seen in OSCEs

Condition Symptoms Signs

Intermittent Pain on exercise ABPI = 0.8–0.06 (falsely high in diabetes
claudication Relief on rest mellitus due to calcified arteries)
Location of pain dictates site of narrowing:
• Aortoiliac disease – buttock claudication and impotence
(Leriche’s syndrome)
• Weak/absent leg pulses (all)
• Iliofemoral – thigh pain , popliteal and foot pulses weak/absent
• Femoropopliteal – calf pain, foot pulses absent/weak
Critical ischaemia Intermittent claudication > rest pain > ulceration > gangrene The ‘6 Ps’ of an acutely ischaemic limb:
Hangs leg out of bed while sleeping (which improves blood flow) • Pain
– may sleep sitting up • Pallor
• Perishingly cold
• Pulselessness
• Paraesthesia
• Paralysis
ABPI = <0.5
Diabetic foot Pain Loss of ankle jerk (autonomic neuropathy)
Skin changes Reduced vibration sense
Charcot joint: severe joint deformity due to lack of sensation and Ulcers
repetitive trauma
Amputation Toes, lower leg or entire leg Above knee
Social impact Through knee
Buerger’s disease: Below knee
• Young male
• Heavy smoker
• Severe Raynaud’s phenomenon

Features of arterial and venous lower limb Important investigations to remember

disease for this station
• Bedside: ABPI, ulcer swab, ECG (arrhythmias and
Arterial Venous ischaemic heart disease), urine dipstick (glycosuria –
Shiny skin Brown pigmented skin diabetes mellitus screen)
Lateral malleolus Medial malleolus • Blood: Full blood count, Us+Es, lipid profile, glucose
Deep ulcer Shallow ulcer • Special tests: Colour duplex ultrasound, angi-
Punched-out Irregular sloping edge ography
Little exudate Lots of exudate
Little/no swelling Oedematous Basic management of peripheral
Cold skin Warm skin vascular disease
No granulation tissue* Granulation tissue* present • Conservative and medical:
Pulses weak/absent Pulses normal • Exercise (there is evidence that this may have even
Increased capillary refill time Normal capillary refill better outcomes than surgery)
(>3 seconds) • Addressing risk factors (weight, smoking, blood
*Granular dark red or pink tissue is seen in wound healing.
pressure, cholesterol, glucose and aspirin).
• Other medications that may be used: cilostazol and
naftidrofuryl
70 Examinations: 14 Vascular (arterial)
• Surgical:
• Endovascular: percutaneous transluminal angi-
oplasty
• Bypass
• Amputation
• Outcomes: approximately one-third improve, one-
third stay the same, and one-third deteriorate.
Hints and tips for the exam
The arterial examination is an easy station and can
allow you to demonstrate a number of clinical skills.
Although you should undoubtedly look for and
comment on features of acute conditions (such as acute
limb ischaemia), seeing such a patient is almost impos-
sible in the OSCE – if you do, it would be reasonable
to stop your examination and get the patient admitted
to the nearest surgical ward!
Adequate exposure
When asking the patient to expose appropriately,
ensure that you are clear and unambiguous. Ask them
to remove their trousers, shoes and socks, leaving their
underwear on. Some actors are told to keep their socks
on unless specifically asked to remove them – forgetting
this can lose you valuable seconds in the OSCE.
It is even more important to treat the patient in a
dignified respectful manner, as many patients feel quite
anxious when asked to expose their legs and abdomen.
Inspect systemically
Inspection is fundamental in all of the vascular exami-
nation, and it is imperative that you are systematic –
inspect either from the hips towards the feet or vice
versa.
Ulcers
When examining for ulcers, make sure that you inspect
all the pressure points and in between the toes (where
an ulcer can easily be missed.) Lift each foot up to look
at the heel, and use this opportunity to comment on
the back of the leg as well. Arterial ulcers are classically
‘punched-out’.
When describing an ulcer comment on:
• Site • Floor
• Size • Exudate
• Shape • Surrounding skin
• Edge
Palpating peripheral pulses
When palpating the pulses, it is easiest to start at the
femoral arteries. If these pulses cannot be felt, the
problem is above this level and the pulses below are
unlikely to be felt. Never say that you can feel a pulse
when you cannot! Simply add that you would like to
have a Doppler scan at the end of the examination to
assess the pulses you could not palpate.
The popliteal pulse is best felt with the patient’s legs
slightly bent and relaxed. Grasp the calf with both
hands. Place your thumbs on the tibial tuberosity and
use your fingers to feel behind the knee in the popliteal
fossa. The popliteal pulses can be difficult to feel so do
not waste much time attempting this.
To save time, palpate both pairs of femoral and the
foot pulses simultaneously. The abdominal aorta
should be felt in the midline above the umbilicus (it
bifurcates at L4 – below the umbilicus).
Don’t forget to check the capillary refill time as this
is also a good indicator of perfusion – up to 2 seconds
is normal, whereas more than 3 seconds shows that the
limb is poorly perfused.
Buerger’s test
This has traditionally been one of the most feared parts
of the vascular examination – the following bullet point
plan should make it easier for you:
• Ask the patient about pain in the hips, and ask
whether you can lift their legs up.
• Lift both legs and note the angle at which the sole of
the foot goes white.
• Note the angle made between the leg and the bed –
this is Buerger’s angle (<20 degrees signifies severe
ischaemia; normal is >90 degrees).
• Ask the patient to sit up from this position with their
legs over the side of the bed:
• Comment on any change in colour of the legs:
bluish (deoxygenated blood) and then red (reactive
hyperaemia) if present.
As the station is quite straightforward, it can be incor-
porated with measuring an ABPI or be followed by
questions on management of the common conditions.
Knowing the arterial tree of the lower limb can assist
you in your examination and impress the
examiner when you finally present your findings
(Figure 14.1).
How to measure an ABPI
Although it is unlikely that this will appear in the OSCE,
you may well be asked to describe the process – espe-
cially if you are aiming for a merit or distinction:
• The patient lies on the bed.
• Their legs must be at rest for 20 minutes before the
measurement and the patient must be horizontal
(remember to state this).
 Examinations: 14 Vascular (arterial) 71

Abdominal aorta

Aorto-bifemoral bypass –
for aortoiliac disease
Common iliac
10% mortality (therefore
may initially attempt iliac
Internal iliac stent and femoro-femoral
External iliac
crossover)

Femoral (pulse felt at mid-inguinal point)

Profunda femoris Femoropopliteal or femorodistal

Superficial femoral bypass – ideally use long
saphenous vein and destroy
valves with valvulotome

Popliteal (felt in popliteal fossa)

Anterior tibial Posterior tibial

(felt just below and
Dorsalis pedis behind medial malleolus)
(felt between
1st and 2nd
metatarsals)

Figure 14.1 Diagram of the arterial tree of the lower limb

• Select an appropriately sized cuff for the patient’s
arm.
• Measure the systolic blood pressure in the arm.
• Use the appropriate cuff for the calf and place the cuff
above the malleoli at mid-calf level.
• Use Doppler scanning at either the dorsalis pedis or
posterior tibial pulses (if you are struggling to locate
the dorsalis pedis, move to the posterior tibial).
• Inflate above the systolic blood pressure measured in
the arm.
• Slowly deflate until the pulse is again heard on the
Doppler.
• Use the higher of two readings (although you will
only have time to take one in the exam).
• Offer to repeat on the other leg.
• Calculate ABPI = ankle pressure/arm pressure
• Normal = 1 or more
• Intermittent claudication = 0.6–0.8
• Rest pain = 0.3–0.6
• Ulceration and gangrene = <0.3
• If the result is normal, you should offer to repeat
the test after the patient has undertaken a bout of
exercise.
• Diabetic patients may have falsely reassuring ABPIs
due to calcification of their arteries.
Questions you could be asked
Q. Describe the anatomy of the lower limb arterial tree
A. See Figure 14.1.
Q. Identify and describe common vascular surgical
scars.
A. Try to find these on the wards – even if it takes a
whole day:
• Open aneurysm: midline laparotomy
• Femoro-femoral crossover: bilateral longitudinal
groin incisions
• Femoropopliteal bypass: longitudinal incisions
above and below the knee
• Carotid artery: longitudinal incision in the neck
72 Examinations: 14 Vascular (arterial)
Q. Discuss the potential complications of vascular
surgery.
A. In your answer, classify these as:
• Intraoperative: bleeding, infection, thrombosis
• Early: compartment syndrome (treat with fasci-
otomy), reperfusion injury
• Late: infection, stenosis, false aneurysm (haem-
atoma outside the arterial wall), amputation
Q. What are the indications for elective abdominal
aortic aneurysm repair (placing an endovascular stent
through the femoral artery)?
A. • Size >5 cm
• Expansion rate >1 cm/year
• Symptomatic (back pain, distal emboli, tender
abdomen)