Evaluation of peripheral circulation

Definition:

 The evaluation of peripheral circulation involves a series of tests and observation often performed alongside a routine cardiovascular examination.

Test procedure and findings:

Firstly, with the patient suitably undressed and lying inclined, focusing primarily on the extremities, observe the patient for any of the following:

    o Gangrene and/or pre-gangrenous changes.
    o Ulcers and/or old ulcer sites, note that these may be venous and/or arterial. Arterial ulcers tend to be painful whereas venous are not.
    o Skin changes such as: pallor and/or colour changes, varicose eczema, temperature differences left to right starting distally and moving proximally.
    o Assess the patient’s capillary return by gently pressing on a nail bed and assessing the reaction: normal refill time is of approximately two seconds.
    o Perform Buerger’s test: refer to this section.
    o Any varicosities which you may have come across during your examination should be gently palpated for any signs of hardness and pain which may indicate thrombophlebitis requiring immediate referral and treatment.
    o Assess the diameter of the aorta (refer to this section) and palpate the peripheral pulses comparing left and right, looking for any abnormalities.
    o Evaluate the ankle-brachial index (refer to this section).
    o The abdominal aorta may be auscultated for any bruit.
    o Look at the patient’s eyes for conjunctival pallor (anaemia), xanthelasma (cholesterol deposits on eyelids, due to hyperlipidaemia), and corneal arcus (white arcs in iris, due to hyperlipidaemia).
    • Blood-pressure may be assessed in the legs. With the patient supine. Place the cuff around the mid/distal thigh and listen at the popliteal artery. The lower limb pressure is usually higher than the upper limb by about 10 mmHg. If the lower limb pressure is significantly lower than the upper limb, this may be indicate the development of peripheral vascular disease affecting the lower limbs. Other aetiologic factors include;
    o Vascular disease of the upper extremity (such as Takayaso)
    o A condition of high stroke volume (Hills sign).

Special considerations:

 Other specialised examinations include: ultrasound imaging techniques such as Doppler ultrasound, angiography using a contrast dye, radiography, magnetic resonance imaging, computerised tomography angiography, blood tests and catheter angiography.