Physical Examination of

Peripheral
Vascular Disease
Teguh Marfen Djajakusumah
General surgeon Consultant Vascular Surgery

Division of Vascular Surgery, Department of Surgery

Universitas Padjadjaran Hasan Sadikin Hospital

Peripheral Vascular Disease

DEFINITION

Peripheral vascular disease

refers to any disease or
disorder of the circulatory
system outside of the brain
and heart
Bhimji S, Hale KL, Forker AD, Talavera F, Adler J. Peripheral Vascular Disease.
http://www.emedicinehealth.com/peripheral_vascular_disease/ article_em.htm

Peripheral Vascular Disease:

Arterial disease

Atherosclerosis obliterans
Vasculitis (Takayasu, Buerger, etc.)
Others
Venous disease

Lymphatic disease

Vascular anomalies

Peripheral Artery Disease (PAD)

Chronic venous disease (CVD)

Venous thromboembolism (VTE)
Lymphedema

Peripheral
Artery Disease
DEFINITION:
Peripheral arterial disease (PAD)
encompasses a range of non-coronary arterial
syndromes that are caused by the altered
structure and function of the arteries that
supply the brain, visceral organs, and the
limbs
Hirsch et al. ACC/AHA Practice Guidelines. ACC - www.acc.org; AHA - www.americanheart.org, 2005.

Peripheral Artery Disease (PAD)

Location
Lower extremity: commonest
Others: upper extremity, carotid, iliac,
Type of disease:
Narrowing (stenosis) and obstruction
Dilatation: aneurysm

Physical examination of PAD

History taking (extremity):

CHRONIC:
Gradual onset of symptoms; intermitten
claudication, ischemic rest pain, dry
gangrene
ACUTE:
Sudden onset of symptoms
Six Ps: Pain, Pallor, Pulselessness,
Poikilothermia, Paresthesia, Paralysis

FONTAINE CLASSIFICATION
Stage I Asymptomatic.
Sub clinical non specific symptom
Paresthesia
Stage II Intermittent claudication.
Stage IIa Intermittent claudication after more
than 200m of pain free walking
Stage IIb Intermittent claudication after less
than 200 meters of walking
Stage III Rest pain.
Troubling pain during the night
Lack of sensory stimuli: focus on their legs
Stage IV Ischemic ulcers or gangrene
(which may be dry or humid).

Chronic:
Atherosclerosis Obliterans (incl
Diabetic foot)
Buergers disease, etc.

Acute Limb Ischemia (ALI)

Symptoms (in order):
1. Sudden onset sensory loss (first
symptom), continued by severe,
throbbing pain
2. Motor nerves: muscle weakness
3. Skin changes: pale, or acute white
leg
4. Muscle pain (last symptom)

ALI:
Emboli

Acute on
Chronic:
Atherosclerosis
Obliterans
AND
Thrombosis

Physical examination of PAD

Always compare
both extremities
/ opposite arteries

Physical examination of PAD

Inspection

Size (sign of atrophy - chronic), swelling (pitting

oedema - infection)
Change in colour: redness (infection), pale, blue,
cyanotic, black
Formation of bullae, ulcers, necrotic tissues, pus
Lack of hair distribution (chronic)
Poor nail growth, loose of nail, autoamputation
(chronic)
Dry skin, scaly skin (chronic)

Inspection (chronic)

Calf muscle atrophy

Dry Gangrene

Dry, scally
skin,
Lack of hair

Inspection

Color changes: cyanotic

Slight Atrophy of right calf

Inspection (acute)

Early sign: almost normal

Late sign: Cyanotic, dark blue, black

Hyperemic and swelling (infection)

Physical examination of PAD

Palpation

Temperature

Cooler temperature compare to opposite extermity

Capillary refill (N: < 2sec)

Pain and tenderness
Palpation of the arterial pulses (arterial
survey)

Dorsal pedis, posterior tibial, popliteal, femoral,

abdominal aorta, radial, ulnar, brachial, and carotid

Acute Limb Ischemia (ALI):

Rutherfords classification

Physical examination of peripheral

arterial disease (Video)

Palpate the pulse of lower extremities

Physical examination of
peripheral arterial disease (Video)

Palpate femoral arteries and abdominal aorta

Physical examination of peripheral

arterial disease (Video)

Palpate the pulse of upper extremities and carotid

Physical examination of
peripheral arterial disease

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Physical examination of
peripheral arterial disease
The Ankle-Brachial Index

To determine possibility of lower extremity

arterial narrowing / stenosis / obstruction

Ankle systolic pressure (mmHg)

Brachial systolic pressure (mmHg)

The Ankle Brachial Index

Normal Value:

Normal:

Intermitten
Claudication:

> 0.9
0.5 0.9

Rest pain, ulceration,

gangrene (severe
ischemic)

< 0.5

Ankle
Brachial
Index
(ABI)

Das P, Steen LH,

Mukherjee D. CAD
in patient with
Peripheral Arterial
Disease. Dalam:
Dieter RS, Dieter
RA, Dieter RA Sr.
Peripheral Vascular
Disease. McGrawHill Medical, 2009.
Pg 187

Determination of ankle systolic pressure using

The posterior tibial artery OR dorsal pedis artery
In non-palpable pulse, use a vascular doptone.

Venous Disease

Venous anatomy
SaphenoFemoral Junction

Venous Disease
Chronic Venous Disease (Valves incompetent)

Chronic venous insufficiency

Varicose vein

Venous Thromboembolism (Venous

obstruction)

Superficial venous thromboembolism

Deep Vein Thrombosis (DVT)

bo s i
s
Thro
m
Painful swelling is the main symptom!

Physical examination of
Venous disease
History taking (common symptoms of
venous disease)

Pain, cramps
Onset: sudden, or gradually
Swelling
Varicosities
Skin darkening / hyperpigmentation /
lipodermatosclerosis
Itching / venous eczema
Difficult to heal / Non-healing Ulcer

Physical examination of
Venous disease

Risk factors

Operation
Family history
Diabetic, stroke
Malignancy
Pregnancy
Use of hormonal contraceptive agent
Occupation (usually which involve standing
position in long time)

Physical examination of
Venous disease
Inspection (better in standing position)

Swelling
Distended, tortouise vein (varicosities): better
in standing position
Redness, bluish, or cyanotic
Dark skin colour in supramaleolar (gaiter) area
Ulcer

Large venous varicosity

Small venous varicosity

Lipodermatosclerosis
Skin pigmentation
Varicose vein

Chronic Ulcer on the

GAITER area

Physical examination of venous

disease (Video)

Inspect the vein in both extremities

Physical examination of venous

disease (Video)

Inspect the skin

Physical examination of
Venous disease
Palpation

Warm foot
Tenderness
Pitting oedema
Homans sign

Brodie-Trendelenburg test

Physical examination of venous

disease (Video)

Homans sign for Deep Venous Thrombosis

Physical examination of venous

disease (Video)

Test the patency of perforator or superficial veins valve

 Negative - Positive

Negative with maintained pressure; incompetent

of perforators
Positive with release pressure; incompetent of
sapheno-femoral veins

Positive Negative

Positive with maintained pressure; incompetent of

perforators
Negatife with release pressure; incompetent of
sapheno-femoral veins

Positive Positive

Incompetent of both perforators and saphenofemoral veins

Thank You