This document provides guidance on performing a vascular examination, including: 1) It outlines the key anatomy of the arterial and venous systems and common pathologies. 2) It describes the equipment, patient positioning, and steps needed for a full examination, including inspection, palpation, auscultation, and testing pulses and blood pressures. 3) Examination techniques are provided to assess the peripheral arterial system, abdominal aorta, and lower limb venous system for varicosities, reflux, and sites of incompetence.

1. Vascular Examination
Ashley Southall Sept 2005

3. Overview
Quick anatomy
Quick pathology
Scheme for examining peripheral vascular
system

4. Anatomy
Arterial and venous systems

5. Arterial anatomy
Aorta
Common iliacs
External iliacs
Common femoral
Superficial femoral
Popliteal
Anterior and
Posterior Tibials
Peroneal
Dorsalis pedis

7. Pathology
Atheroma and occlusion
Aneurysms
Skin changes e.g. ulcers, gangrene

8. Examination
Necessary equipment
Introduce yourself
Privacy
Position
Light
Expose

9. Examination
N
I
P
P
L
E

10. Examination
Necessary equipment
Introduce yourself
Privacy
Position
Light
Expose

11. Examination
Full cardiovascular exam
Claudicants 20% 5yr mortality
Assess fitness for surgery
In exam tell this to examiner at end

12. Inspection
Look around the bedside for clues
Tablets/ inhalers/ sprays
Oxygen
Heparin pumps
Artificial limbs
Insulin pumps/ syringes
Cigarettes!

13. Inspection
Inspect the patient as a whole
In pain?
General appearance

14. Inspection
Hands
Nicotine staining of fingers
Amputations

15. Inspection
Abdomen / groins
Obvious pulsatile mass (AAA)
Scars
AAA repair
Fem-pop bypass

17. Inspection
Legs
Scars
Pallor
Venous guttering
Discoloration
Ulcers

18. Inspection
Pressure areas
Malleoli
Heel
Ball of foot
Head of 5th metatarsal
Tips of the toes
Between toes

19. Palpation
Temperature (back of hand)
Capillary refill
Pulses

20. Palpation
Pulses
Femoral
Popliteal
Dorsalis pedis
Posterior tibial

21. Palpation
Femoral pulse
Landmark – mid-inguinal point

24. Palpation
Popliteal pulse
Place thumbs on tibial tuberosity
Press fingers firmly into lower part of
popliteal fossa

25. Palpation
Dorsalis pedis
Starts midway between the malleoli
anteriorly (continuation of ant. tibial)
Runs to cleft between first and second
metatarsal bones

28. Palpation
Posterior tibial
Behind the medial malleolus

31. Palpation
Test muscle power and sensation
Palpate for AAA

32. Auscultation
Listen for bruits
Abdominal aorta
Renal arteries
Iliacs / femorals
Adductor canal (2/3 down antero-medial
thigh)

33. Other
Buerger’s angle
Support the patient’s heel
Ask pt to raise leg to 90°
Should stay pink to 90°
Foot pale at 50° = severe ischaemia
Foot pale at 25° = critical ischaemia

34. Other
Swing legs over edge of bed
If legs go engorged and purple, Buerger’s
test = positive

35. ABPIs
Ankle Brachial Pressure Index
Take BP in both arms with Doppler US
probe
Take BP with cuff around lower leg using a
Doppler US probe
(highest cuff pressure at which pulse can
be heard)
Leg BP/ Arm BP = ABPI

36. ABPI
Clinical status ABPI
Symptom free 1 or more
Intermittent claudication 0.95 - 0.5
Rest pain 0.5 - 0.3
Gangrene and ulceration <0.2

37. Venous Exam
Lower limb venous anatomy
Superficial and deep systems
Long and short saphenous systems
Perforators with valves
Deep system within leg muscles

41. Inspection
Expose patient (both legs visible to groin)
Stand patient up
Inspect the leg

42. Inspection
Look for
Varicose veins
Venulectasias (small venous stars)
Haemosiderin deposits
Lipodermatosclerosis
Ulcers
Venous eczema
Scars – previous ulcers, surgery
Thrombophlebitis

50. Palpation
Palpate varicosities
Palpate saphenofemoral junction
Locate femoral artery
Mid-inguinal point halfway between ASIS
and pubic symphysis
Femoral vein lies approx 1cm medial to
this (NAVY)

51. Palpation
Saphenofemoral junction lies approx 2cm
below this.
Keep one hand on saphenofemoral
junction
Tap varicosity
If saphenofemoral junction is incompetent,
thrill may be felt

52. Palpation
Doppler test
Place probe over SFJ
Compress varicosity
Whoosh heard as vein compresses
If incompetent long whoosh heard when
released

53. Palpation
Can also do this for sapheno-popliteal
junction

55. Palpation
Trendelenberg test
Lie patient down
Raise leg to empty varicosities
Apply pressure to SFJ to occlude it
Maintain the pressure while getting the pt to
stand
If varicosities do not refill, saphenofemoral
incompetence is present

56. Palpation
Tourniquet test
As for Trendelenberg
Apply tourniquet to upper thigh
Stand patient up
If varicosities fill, level of incompetence is
below the tourniquet

57. Palpation
Repeat the test with the tourniquet at
different levels
Level of incompetence between lowest
tourniquet level at which veins still filled
and level of tourniquet when veins
controlled

59. Further tests
Full abdominal exam
Arterial exam
Duplex ultrasound
scanning

60. Thank you