Peripheral arterial disease physical examination

Peripheral arterial disease Microchapters
Home
Patient Information
Overview
Classification
Pathophysiology
Causes
Differentiating Peripheral arterial disease from other Diseases
Epidemiology and Demographics
Risk Factors
Screening
Natural History, Complications and Prognosis
Diagnosis
History and Symptoms
Physical Examination
Laboratory Findings
Electrocardiogram
Chest X Ray
CT
MRI
Ultrasound
Other Imaging Findings
Other Diagnostic Studies
Treatment
Medical Therapy
Surgery
Primary Prevention
Guidelines for Management
Case Studies
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
Peripheral arterial disease physical examination On the Web
Most recent articles
Most cited articles
Review articles
CME Programs
Powerpoint slides
Images
American Roentgen Ray Society Images of Peripheral arterial disease physical examination All Images X-rays Echo & Ultrasound CT Images MRI
Ongoing Trials at Clinical Trials.gov
US National Guidelines Clearinghouse
NICE Guidance
FDA on Peripheral arterial disease physical examination
CDC on Peripheral arterial disease physical examination
Peripheral arterial disease physical examination in the news
Blogs on Peripheral arterial disease physical examination
Directions to Hospitals Treating Peripheral arterial disease
Risk calculators and risk factors for Peripheral arterial disease physical examination

Editors-in-Chief: C. Michael Gibson, M.D., Beth Israel Deaconess Medical Center, Boston, MA; Robert G. Schwartz, M.D. [1], Piedmont Physical Medicine and Rehabilitation, P.A.; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]

Please help WikiDoc by adding more content here. It's easy! Click here to learn about editing.

Physical Examination

Vitals

• Decreased or absent pulses
• Palpation of the carotid pulses and notation of the carotid upstroke and amplitude and presence of bruits.
• Palpation of the pulses at the brachial, radial ulnar, femoral, popliteal, dorsalis pedis, and posterior tibial sites. 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
• Measurement of blood pressure in both arm and notation of 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.)

ACC/AHA 2005 Practice Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic) (DO NOT EDIT)

Recommendations for Clinical Presentation in Asymptomatic PAD Patients

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 III

"1. Angiotensin-converting enzyme (ACE) inhibition may be considered for individuals with asymptomatic lower extremity PAD for cardiovascular risk reduction. (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 (Table 2) 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)"

ACC/AHA 2005 Practice Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic) (DO NOT EDIT)

Recommendations for Critical Limb Ischemia in PAD Patients

Class I

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

Recommendations for Acute Limb Ischemia in PAD Patients

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

Template:WikiDoc Sources