Peripherl Vascular Diseases

8/10/2019 Peripherl Vascular Diseases

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PERIPHERAL VACULAR DISEASES

This lecture will be about the vascular diseases, this specialty includes the arteries and veins of all parts of

the body except the coronaries (related to cardiac specialty) and the cerebral vessels.

Arterial diseases

They are manifested as

Upper limb and/or lower limb ischemia. Most of the talk in this lecture will be actually about the

lower limb ischemia,

Neurologic symptoms due to carotid problems, as most of the CVA "cerebrovascular accidents" are

caused by embolus from the carotids, or problems in the vertebrobasilar system at the base of the

brain,

Abdominal symptoms due to visceral ischemia, abdominal aortic aneurysm, or vasospastic

symptoms.

Notes from macleod's :

Only a quarter of PAD "peripheral arterial diseases" cases are symptomatic. The underlying pathology is

usually atherosclerosis (hardening of the arteries) affecting large and medium-sized vessels.

Identifying patients with PAD is important for the following reasons:

PAD, even if asymptomatic, is a powerful marker for premature vascular death

The first manifestation of PAD may be a life- or limb-threatening complication, e.g. stroke, acute

limb ischaemia or ruptured AAA

Modifying vascular risk factors dramatically improves outcomes

PAD may affect medical and surgical treatment for other conditions, e.g. prescription of a beta-

blocker may precipitate intermittent claudication

LOWER EXTREMITY ARTERIAL DISEASES

Peripheral arterial diseases affect the legs 8 times more commonly than the arms for the following reasons;

the arterial supply to the legs is less well-developed in comparison to the muscle mass, and the

atherosclerosis is more frequent in the lower limbs.

Ischemia "lack of blood supply" in the lower limbs could be chronic, acute, or acute on top of chronic

ischemia.


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Chronic arterial disease in the lower extremities.

It is a very common problem especially in the elderly, usually they are outpatients (referred to the clinics),

while the patients of acute lower limb ischemiaand acute over chronic- are referred to the emergency

room.

A picture of atherosclerosis that might present as stenosis which could be mild or severe. The body response

in the chronic problems is by forming collateral circulation that completely or partially relieves his

symptoms.

Fontaine classification system for the presentation of patients with chronic lower limb ischemia:

Stage 1; asymptomatic, so the patient might have atherosclerosis in the vessels and stenosis, but he is

asymptomatic not complaining of any pain. So, either the disease is mild or the patient himself doesnt move

around, as in old age patients or patient with a problem that limits his movement as joint problems " their

exercise tolerance is limited by other comorbidities."

Note from macleod's:

Although asymptomatic, these patients are at high risk of vascular complications and should be assessed

and treated medically as if they have intermittent claudication.

Stage 2; intermittent claudication, pain after walking for a certain distance.

It is a pain felt in the legs on walking due to arterial insufficiency, felt as tightness, cramp-like pain, this pain

is felt after a relatively constant distance, the distance is shorter if walking uphills, in the cold "as it causes

vasoconstriction in the arteries to produce heat" or after meals.


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It is important to know the "claudication distance" before which the patient develops the disease. If the

distance is less than 200 m on flat surface then this is classified as B, if it is more than 200 m then this is

classified as A.

The site of the pain is only in the legs if the disease is femoropopliteal obstruction, or in the thigh and

buttocks if the atherosclerosis was aortoiliac. "The pain is felt one segment below the level of obstruction."

The pain will disappear upon resting for few minutes. This pain is reproducible, so if the patient walked for

the same distance, then the pain will appear again. The pain results because of the increased demand in the

leg that is not provided by the artery which suffers from PAD.

It is important to put in mind that the claudication is not only arterial, we Have another two types of

claudication which are:

The neurogenic claudication, due to neurological and musculoskeletal disorder in the lumbar spine.

The venous claudication due to venous outflow obstruction from the leg, following extensive DVT.

ALL THE TABLE IS INCLUDED

The clinical features of arterial, neurogenic and venous claudicationArterial Neurogenic Venous

Pathology Stenosis or occlusion of majorlower limb arteries

Lumbar nerve root orcauda equina compression(spinal stenosis)

Obstruction to the venousoutflow of the leg due toiliofemoral venous occlusion

Site of pain Muscles, usually the calf but mayinvolve thigh and buttocks

Ill defined. Whole leg. Maybe associated withnumbness and tingling

Whole leg. 'Bursting' innature

Laterality Unilateral if femoropopliteal, and

bilateral if aortoiliac disease orside more than the other

Often bilateral Nearly always unilateral

Onset Gradual after walking the'claudication distance'

Often immediate onwalking or standing up

Gradual, from the momentwalking starts

Relievingfeatures

On stopping walking, the paindisappears completely in 1-2minutes

Bending forwards andstopping walking. May sitdown for full relief

Leg elevation

Colour Normal or pale Normal Cyanosed. Often visiblevaricose veins

Temperature Normal or cool Normal Normal or increased

Oedema Absent Absent Always present

Pulses Reduced or absent Normal Present but may be difficultto feel owing to oedema

Straight-legraising

Normal May be limited Normal


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Stage 3; pain at rest (night pain), at rest the cardiac output decreases and as a consequence the blood flow

to the limbs also decreases. When the patient wakes up due to the pain, dangling his legs from the bed, the

blood flow to the limbs will increase so the pain will be relieved.

In macleod's words:

The pain is due to poor perfusion resulting from the loss of the beneficial effect of gravityon lying down and

the reduction in heart rate, blood pressure, and cardiac output that occurs when sleeping.

Patients often obtain relief by hanging the leg out of bed or by getting up and walking around. However, on

return to bed, the pain recurs and patients often choose to sleep in a chair. This leads to dependent

oedema, increased interstitial tissue pressure, a further reduction in tissue perfusion and ultimately a

worsening of the pain.

It indicates severe, multilevel, lower limb PAD.

Stage 4; ulceration or gangrene. Usually dry gangrene, sometimes wet.

Dry gangrene is without infection, wet gangrene is associated with infection.

Patients with severe lower limb PAD, even trivial injuries to the feet fail to heal. "The mediators for tissue

repair are not enough in the site of injury because of ischemia". Bacteria will enter leading to gangrene or

ulceration.

Stage 3 and stage 4 are known as critical limb ischemia, persistent ischemia.

It requires analgesics because the pain is continuous even at rest. This patient typically have ankle blood

pressure < 50 mmHg or toe pressure of less than 30 mmHg, and a positive Buerger's test "discussed later".

Ischemia signs include absence of hair, thin skin, brittle nails. The absence of foot pulses doesnt doesntcompletely exclude significant lower limb PAD, but they are almost always diminished or absent.

Lerich's syndrome

Atherosclerosis in the abdominal aorta and iliac vessels that will result in claudication in the buttocks and the

thigh, Absent or decrease femoral pulses, and impotence are the three cardinal signs of the lerich's

syndrome.

Acute limb ischemia

Caused by

It could be thromboembolism from the left atrium associated with atrial fibrillation; in a patient

having normal peripheral vessels who have atrial fibrillation, so there is an embolus in the heart, and

with arterial fibrillation this embolus will travel to reach a region of bifurcation. The regions of

bifurcation are more liable to be obstructed by an embolus because in these regions there is acute

change in the diameter of the vessel occur. The blood to the lower limbs will stop acutely. This case

may develop to wet gangrene within hours.

It could be thrombotic of an already narrowed atherosclerotic segment.

Compartment syndrome due to increased pressure in the fascial compartment of the leg, mostly in

the calf, which compromises the perfusion and viability of muscles and nerves, so there will be no

blood supply. Severe pain that is not relieved with opioids, exacerbate with movements.


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Signs of acute limb ischemia

6P's that are divided into soft signs and hard signs:

Soft signs are; Pulseless, Pallor, Perishing cold

hard signs that indicate a threatened limb are Paresthesia, Paralysis, and Pain on squeezing muscles.

Parasthesia and paralysis are associated with nerve ischemia.

A limb with these features usually becomes irreversibly damaged unless the circulation is restored within

few hours.

Embolus Thrombosis

Onset andseverity

Acute (seconds or minutes), ischemia profound (nopre-existing collaterals)

Insidious (hours or days), ischemia lesssevere (pre-existing collaterals)

Embolic source Present (usually atrial fibrillation) Absent

Previousclaudication

Absent Present

Pulses incontralateral leg

Present often absent, because theatherosclerosis is a generalized disease

Diagnosis Clinical, you have to deal with the case directly, inthe operating room to remove the embolus.

Angiography

Treatment Embolectomy and anticoagulation Medical, bypass surgery, thrombolysis

Notes;

Thrombosis usually presented as acute on top of chronic, so that there is already chronic limb

ischemia and suddenly the patient comes with the 6ps. (it is not necessary to show all the 6 signs to

be diagnosed as acute case), minial blood supply to the limbs because of the presence of collaterals

making the case less severe.

STROKES

(aka; cerebrovascular accident)

Focal central neurologic deficit of a vascular cause. 80% of strokes are ischemic as opposed to thehemorrhagic strokes that represent 20% of cases.

Transient ischemic attack (TIA) is a stroke in which the symptoms relieve within 24 hours. These

cases are not associated with infarction, but later on the patient have higher risk to develop frank

stroke.

Note; the doctor didnt mention anything else about the strokes.


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Additional Notes, not mentioned by the doctor:

Remember that the blood supply to the brain is mainly through the anterior and the middle

cerebral arteries that originate from the internal carotid artery, and the posterior cerebral artery

that originates from the vertebrobasilar system that in turn originates from the subclavian artery.

Both systems (the internal carotid system and the vertebrobasilar system are connected to each

other through the circle of Willis).

Carotid artery territory (anterior circulation)

Up to half of all strokes and TIAs are due to embolism from an atheromatous plaque at the origin of

the internal carotid artery. Clinical features vary according to the cerebral area involved but can

include motor deficit, visual field defect or difficulty in speech.

Vertebrobasilar artery territory (posterior compartment)

TIAs and strokes in this territory cause giddiness, collapse with or without loss of consciousness,

transient occipital blindness or complete loss of vision in both eyes. Subclavian artery stenosis or

occlusion proximal to the origin of the vertebral artery may cause vertebrobasilar symptoms as part

of the 'subclavian steal' syndrome. This happens when the arm is exercised. The increased blood

requirement in the arm is met by blood travelling up the carotid arteries and then, via the circle of

Willis, down the vertebral artery into the arm, so 'stealing' blood from the posterior cerebral

circulation. Signs of this include asymmetry of the pulses and BP in the arms, sometimes with a

bruit over the subclavian artery in the supraclavicular fossa.


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ABDOMINAL SYMPTOMS

Mesenteric angina

Severe central abdominal pain typically develops 10-15 minutes after eating. The patient becomes

scared of eating with significant weight loss as a result of that, this is a universal finding. Diarrhea

may occur.

From macleod's: "because of the rich collateral circulation, usually two of the three major

visceral arteries (celiac trunk, superior and inferior mesenteric arteries should be occluded

before the symptoms and signs of the chronic mesenteric arterial insufficiency occur)".

From Robbin's: such cases are mostly associated with hypoperfusion rather than obstruction.

The mesenteric ischemia could also be acute, due to embolus or thrombosis, this patient comes to

you with shock, severe abdominal pain, bloody diarrhea, profound metabolic acidosis. This ischemia

may progress to bowel gangrene.

From Robbin's: risk factors for acute mesenteric angina "ischemic bowel disease" include

recent major abdominal surgery, recent myocardial infarction, atrial fibrillation, or

manifestations suggestive of some form of vegetative endocarditis. Because of the high

mortality rate associated with these acute cases, high index of suspicion, especially in the

presence of the risk factors, is a must.

Abdominal aortic aneurysm (AAA),

Usually in elderly, and maybe incidental finding in ultrasounds. (It is an abnormal dilatation of the aortaand is present in 5% of men aged >65 years).

If it is large it may appear as a pulsatile abdominal mass, expensile palpation.

The most common risk factors are smoking and hypertension, AAA is three times more common in

males than in females.

Aneurysms in the aorta are usually degenerative, associated with atherosclerosis that will lead to

dilatation of the aortic wall. Other causes are inflammatory, infectious and others.

Most patients are asymptomatic until the aneurysm ruptures.

A ruptured AAA is commonly misdiagnosed as renal colic. So a man more than 60 years presented

with "renal colic" is having a ruptured AAA until proven otherwise.

VASOSPASTIC SYMPTOMS

Raynaud's phenomena is digital ischemia that is induced by cold and emotion and has three

phases;

Pallor due to digital artery spasm or obstruction.

Cyanosis, due to deoxygenation of static venous blood (this phase may be absent)

Redness, due to reactive hyperemia


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Raynaud's phenomenon may be primary (Raynaud's disease) and due to idiopathic digital artery

vasospasm, or secondary (Raynaud's syndrome) due to a long list of problems seen in the table

below.

6.38 Diseases associated with secondary Raynaud's syndrome

Connective tissue syndromes, e.g. systemic sclerosis, CREST (calcinosis,Raynaud's phenomenon, oesophageal dysfunction, sclerodactyly,telangiectasia) and systemic lupus erythematosus

Atherosclerosis/embolism from proximal source, e.g. subclavian arteryaneurysm

Drug-related, e.g. nicotine, beta-blockers, ergot

Thoracic outlet syndrome

Malignancy

Hyperviscosity syndromes, e.g. Waldenstrm's macroglobulinaemia,polycythaemia

Vibration-induced disorders (power tools)

Cold agglutinin disorders

History taking in arterial diseases

In taking history from a patient with a vascular disease, we should focus on:

The risk factors for atherosclerosis (atheroma); smoking, hypercholesterolemia, hyperlipidemia,

hypertension, diabetes, not exercising. Specifically ask about "diabetes" because it is associated with early

development and rapid progression of widespread atheroma.

Associated cardiac symptoms, for example, atherosclerosis is a generalized systemic disease that can affect

the coronaries, so those patients may have associated cardiac problems.

Pat history, previous myocardial infarction, previous surgeries.

Family history, because it may present as premature arterial disease, a patient of 25 or 30 years old having

ischemic heart diasease or lower ischemia due to familial problems.

Sexual activity, can be affected also by atherosclerosis in males with gluteal intermittent claudication

because of a stenosis in the aorto-iliac level.


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Physical examination in arterial diseases

Physical Examination of patients with PVD

Review

-A symptom is something described by the patient

-A sign is an observation seen by examination

Things to note in the general examination

- Tobacco stains,

- discoloration of fingers or hands, that may indicate an atheroembolism from a proximal

subclavian aneurysm.

- Pits and healed scars in the finger pulps, indicates secondary raynaud's phenomena

- Changes in the nails

- Wasting of the small muscles of the hand, in thoracic outlet syndrome.

- Corneal Arcus and Xanthalesma (signs of hyperlipidemia)

- Horners syndrome(in carotid artery aneurysm), hoarseness of voice (recurrent laryngeal

nerve palsy from a thoracic aortic aneurysm) etc

Note, horners syndrome (ptosis, anhidrosis, and miosis) along with hoarseness of the voice

could be seen in cases of pancoast tumors (tumors in the apex of the lung)

Regional examination

Abdomen

-Examine the abdomen for any pulsation suggesting aortic aneurysms. (AAA presents as expensile

pulsation in the epigastric region)

-Auscultate over the renal arteries to listen for any bruit suggesting renal artery stenosis "the most

common cause of secondary hypertension".


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Arms

-Measurement of the radial and brachial pulses as well as blood pressure bilaterally. (Important in

subclavian stenosis, and aortic dissection with a subclavian problem). Up to 2mm Hg difference isnormal.

Neck

-Carotid pulse palpation and auscultation looking for a bruit (may indicate stenosis).

During inspection and palpation of the lower limb:

(i) Color changes of the limb (Cyanosed, pale, erythematous)

(ii) Amputations

(iii) Ulcers

(iv)Spaces and heels

(v) Signs of ischemia (hair loss, muscle atrophy, tenderness)

(vi)Capillary refilling: compress the finger or toe to remove the blood and count how long does it

need to get the color back. Up to 3 seconds is normal. Delayed capillary refill indicates ischemia.

(vii) Neurological exam (sensory and motor)

(viii)Pulses in the lower limb (measured distal to proximal or vice versa):

Femoral pulse

Anatomy: the femoral artery can be felt at the midinguinal point (between ASIS and

symphysis pubis).

-Asses the femoral pulse by palpation and auscultate for a bruit

Popliteal artery: in the popliteal fossa. Raise the

patients leg 30 degrees and feel for the popliteal

pulse. Can be done while patient is in a supine

position.

From macleod's: the popliteal srtery is always hardto feel. If you feel it easily then consider the

possibility of popliteal aneurysm.

Anterior tibial and posterior tibial pulses

Anatomy: Aorta bifurcates at the level of the

umbilicus into the common iliacs, then it splits

into an external and internal iliac lower down.

The external iliac as it passes the under the

inguinal ligament gives the common femoral

artery, which in turn divides in the upper thigh

into a superficial femoral branch and a deep


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femoral profundus branch. The superficial branch continues as the popliteal artery, below

the knee, the popliteal artery makes a trifurcation, dividing into anterior tibial, posterior

tibial and peroneal (deep, we cant palpate it, it passs deep between the tibia and fibula),

the posterior tibial passes in the medial aspect behind the medial malleolus, 2 cm behind

and below the medial malleolus. This is the site where we palpate the posterior tibial pulse.The anterior tibial continues as the dorsalis pedis on the dorsal aspect of the foot, palpable

in the dorsum of the foot lateral to the tendon of extensor halluces longus over the

navicular bone.

Then you have to write your comment about the pulses, you have to draw a picture like this, if the

pulse is normal then put + sign, if It is absent then put thesign, if it reduced then put , if it is

exaggerated as in the cases of aneurysms in the femoral artery or I the popliteal artery then put ++.

Buerger's test

With the patient lying supine, stand at the foot of the bed. Raise the patient's feet and support the

legs at 45 to the horizontal for 2-3 minutes

Watch for pallor with emptying or 'guttering' of the superficial veins

Ask the patient to sit up and hang the legs over the edge of the bed

Watch for reactive hyperaemia on dependency; the loss of pallor and spreading redness

(dependent rumor) is a positive test.

Ankle-brachial index (ankle to brachial pressure index)

You have to measure the blood pressure in the brachial artery as usual, then you have to measure

the systolic blood pressure in the leg,

Use a hand-held Doppler and a sphygmomanometer

The vascular angle, which is also called buerger's angle, is the angle to which the leg has to

be raised before it becomes pale. In a limb with a normal circulation the toes stay pink, even

when the limb is raised by 90 degrees. In an ischaemic leg, elevation to 15 degrees or 30

degrees for 30 to 60 seconds may cause pallor. A vascular angle of less than 20 degrees

indicates severe ischaemia.

In arterial disease, on returning the leg from the raised position, and hanging it over the side

of the bed, the leg will revert to the pink colour more slowly than normal. Moreover, the

affected leg will pass through the normal pink colour to a red-range colour (often known as

sunset foot) due to the dilatation of the arterioles in their attempt to remove the metabolic

waste that has built up, through the phenomenon of reactive hyperaemia. Finally, the limb

will then revert to its normal colour.

Reactive hyperaemia is the transient increase in organ blood flow that occurs following abrief period of ischaemia. Following ischaemia there will be a shortage of oxygen and a

build-up ofmetabolic waste.


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Hold the probe over the posterior tibial artery

Inflate a BP cuff round the ankle

Note the pressure when Doppler signal disappears. This is the systolic pressure in that artery

as it passes under the cuff

Repeat holding the probe over dorsalis pedis, and then the perforating peroneal

Measure the brachial BP in both arms, holding the Doppler probe over the brachial artery at

the elbow of the radial artery at the wrist.

Doppler is a small instrument that has an ultrasound probe, this probe detects blood flow, with

each flow, this instrument will produce a sound (as it replaces the usual stethoscopes)

Calcified arteries will not close (they will give you false reading), seen in diabetic patients who have

incompressible, calcified crural arteries.

Normal finding in buerger's test

The blood pressure in the leg is equal or more than that in the brachial artery.

Abnormal finding in buerger's test

Ischemic patients will have a low pressure in their legs. Then when you divide the blood pressure in

the leg to the blood pressure of the brachial artery , the result will be less than 1

0.91.3 ,, normal

0.70.9 ,, mild ischemia

0.40.7 moderate

Less than 0.4 severe ischemia


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The venous system

The venous system in the lower limbs is divided

into superficial and deep veins:

The superficial system in the lower limb is

composed of the short and long

saphenous and the venous arch.

The deep system is composed of the veins

that goes with the arteries.

90% of blood flow goes across the deep system,

and the other 10% goes across the superficial

system.

There is communications between the two

systems at the saphenofemoral junction where

great saphenous vein drains into the femoral vein,

and there are some perforators in the leg passesthrough the fascia connecting the deep and

superficial system.

Examples of venous diseases are:

In the superficial system: varicose veins, in

addition to superficial thrombosis.

In the deep system: deep vein thrombosis(DVT) or chronic venous insufficiency.

As you know venous leg is different than arterial

leg; where venous leg is swollen with pain and discoloration and ulcerations usually after chronic

venous insufficiency.


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Varicose veins:

dilated tortuous superficial veins, maybe a primary idiopathic (familial) or secondary to obstructionat the deep system or to valve destruction.

It maybe asymptomatic or they may cause pain or discomfort.

When you want to examine varicose veins, you have to ask the patient stand because in supine

position these superficial veins empty so they will not appear.

Trendelenburg test

We have a test called Trendelenburg test or tourniquet test to know where the problem is

How you do this test?

You tell the patient to lie on bed, you raise his legs up to empty the veins, after they disappear you

put a tourniquet at the thigh and then you ask the patient to stand up while the tourniquet is tied

on his thigh. If the problem is at the saphenofemoral junction (reflux at this site), then the veins will

not be filled back, if the problem is at the perforators those varicose veins will fill back.

Q from student: what if the veins are filled back by arterial flow?

Ans: veins filling by arterial flow need time so it will not be noticed fast like the previous situation.


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Acute deep vein thrombosis:

mostly it occurs at lower limbs and rarely in the upper limbs.

The cardinal symptoms of DVT are; pain, tenderness, swelling and erythema depending on severity

and the site of DVT. It may be distal at the popliteal, or it may be proximal obstructing femoral or

iliac vein where symptoms become more prominent affecting larger area proximally.

Complications of DVT: pulmonary embolism.

Risk factors to develop DVT: Age , malignancy , obesity, varicose veins, family history of DVT , past

history of DVT, surgery (due to long time of resting and that's why we give these patients at risk a

prophylaxis before surgery),paralyzed patient, Oral contraceptive, hormone replacement therapy,

sever illness, hypercoagulable state in familial DVT patients.

DVT is of two types, either occlusive thrombosis or non-occlusive thrombosis. The non-occlusive

thrombosis has negative findings on clinical examination, although it is the one that causes PE.

Chronic venous insufficiency:

Due to impaired venous return causing discomfort skin changes, edema.

Wiki : Chronic venous insufficiency (CVI) is a medical condition

where the veins cannot pump enough oxygen-poor blood backto the heart. It is sometimes referred to as an "impaired

musculovenous pump", this is due to damaged or "incompetent"

valves as may occur after deep vein thrombosis (when the

disease is called postthrombotic syndrome) or phlebitis.

Usually happen because of obstruction of the deep veins. Those

patients have venous hypertension and skin changes in the lower

leg (varicose veins), eczema and ulcerations.

Actually DVT is an acute problem that may resolve or go to

postthrombotic syndrome or it may go to chronic venous

insufficiency.

You see here in the picture a swilling due to venous problem, and there is discoloration at the

ankle, in addition to ulcers. Venous ulcers usually located at the medial aspect of the leg (gutter

area), while the arterial ulcers usually located distally at the toes, and nuerogenice ulcers usually

located at the pressure areas.

In this picture of chronic venous insufficiency you can see the dermatosclerosis and the ulcers

obviously.


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Superficial venous thrombophlebitis

These venous diseases are the first cause of leg swelling, and the other cause is lymphatic

problems.

This condition affects up to 10% of patients with severe varicose veins and is more common duringpregnancy. Recurrent superficial venous thrombophlebitis, especially affecting different areas

sequentially and non-varicose veins, may be associated with underlying malignancy. It may

propagate into the deep system, leading to DVT and pulmonary embolism.

Notes

Most venous diseases are associated with swelling. In the history you should know if this swelling is

acute or chronic, bilateral or unilateral, localized at the legs or generalized all other the body,

congenital or acquired.

Acute swelling examples: DVT, cellulites, joint problems, hematoma, baker cyst, musculoskeletal

problems, arthritis, trauma.

Chronic swelling examples: venous diseases, lymphatic obstruction (lymphedema) which may be

primary or secondary to lymphadenectomy or infection or tumor. Other causes are systemic as

heart failure, hypothyroidism, hypoproteinemia (in liver or renal diseases).

You should check for the edema if it's pitting or non-pitting, you put your finger at the swelling area

for seconds then you see if there is a print or the skin back to its previous situation as you see in

these pictures. And the area when you do this exam is at the dorsum of the foot behind the medial

cellulous over the shin. It's graded from one to four.

And you should also measure the circumference.

The circumference is measured in the area of the largest diameter in the leg (below the tibial

tuberosity by 2 cm), compare the two legs together. A difference less than 2 cm is not significant,

more than that means a swollen limb.

Allen test

To check the patency of the radial and the ulnar arteries,

1) The hand is elevated and the patient/person is asked to make a fist for about 30 seconds.

2) Pressure is applied over the ulnar and the radial arteries so as to occlude both of them.

3) Still elevated, the hand is then opened. It should appear blanched (pallor can be observed at the

finger nails).

4) Ulnar pressure is released and the colour should return in 7 seconds.

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Peripherl Vascular Diseases