How To Perform A Thorough Vascular Exam

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Continuing Education Course #152 — May 2007

I am pleased to introduce the latest article, “How To Perform A Thorough Vascular Exam,” in our CE series. This series, brought to you by the North American Center for Continuing Medical Education (NACCME), consists of complimentary CE activities that qualify for one continuing education contact hour (.1 CEU). Readers will not be required to pay a processing fee for this course.
Peripheral vascular disease can be a key contributing factor in lower extremity amputation. With this in mind, Daniel T. Halloran, DPM, Peter A. Blume, DPM, Michael G. Palladino, DPM, and Bauer E. Sumpio, MD, PhD, offer an informative primer on diagnostic screening tools ranging from the ankle-brachial index (ABI) and segmental limb pressure measurements to the toe brachial index and pulse volume recordings.
At the end of this article, you’ll find a 10-question exam. Please mark your responses on the enclosed postcard and return it to NACCME. This course will be posted on Podiatry Today’s Web site (www.podiatrytoday.com) roughly one month after the publication date. I hope this CE series contributes to your clinical skills.
Sincerely,

Jeff A. Hall
Executive Editor
Podiatry Today

INSTRUCTIONS: Physicians may receive one continuing education contact hour (.1 CEU) by reading the article on pg. 76 and successfully answering the questions on pg. 82. Use the enclosed card provided to submit your answers or log on to www.podiatrytoday.com and respond via fax to (610) 560-0502.
ACCREDITATION: NACCME is approved by the Council on Podiatric Medical Education as a sponsor of continuing education in podiatric medicine.
DESIGNATION: This activity is approved for 1 continuing education contact hour or .1 CEU.
DISCLOSURE POLICY: All faculty participating in Continuing Education programs sponsored by NACCME are expected to disclose to the audience any real or apparent conflicts of interest related to the content of their presentation.
DISCLOSURE STATEMENTS: Drs. Halloran, Blume, Palladino and Sumpio have disclosed that they have no significant financial relationship with any organization that could be perceived as a real or apparent conflict of interest in the context of the subject of their presentation.
GRADING: Answers to the CE exam will be graded by NACCME. Within 60 days, you will be advised that you have passed or failed the exam. A score of 70 percent or above will comprise a passing grade. A certificate will be awarded to participants who successfully complete the exam.
TARGET AUDIENCE: Podiatrists
RELEASE DATE: May 2007
EXPIRATION DATE: May 31, 2008
LEARNING OBJECTIVES: At the conclusion of this activity, participants should be able to:
• discuss clinical signs and symptoms of arterial insufficiency;
• describe how a visual inspection of the color of the foot can enable one to assess the degree of arterial insufficiency;
• describe the location and appearance of lower extremity ulcers caused by ischemia;
• review the importance of segmental pressure measurements;
• explain why the toe brachial index (TBI) is more reliable than segmental pressures in assessing foot perfusion among patients with diabetes; and
• discuss the pros and cons of transcutaneous oxygen (TcPO2).

Sponsored by the North American Center for Continuing Medical Education.

How To Perform A Thorough Vascular Exam
How To Perform A Thorough Vascular Exam
How To Perform A Thorough Vascular Exam
82
Author(s): 
By Daniel T. Halloran, DPM, Peter A. Blume, DPM, Michael G. Palladino, DPM, and Bauer E. Sumpio, MD, PhD

Given the relatively common prevalence of peripheral vascualr disease and its potential complications in the lower extremity, these authors offer key diagnostic insights with a particular emphasis on non-invasive screening tools.


Lower extremity vascular disease is a routine complication with lower extremity wounds, especially in the diabetic population. Peripheral neuropathy and peripheral vascular disease are recognized as contributing factors in lower extremity amputation. It is estimated that more than 5 million people per year experience peripheral vascular disease.1 In 2002, about 82,000 non-traumatic lower limb amputations were performed in people with diabetes.2

   Researchers have shown that basic vascular screening is efficacious in the identification of lower limb peripheral arterial occlusive disease, and that clinicians can incorporate this screening in the initial evaluation of the at-risk patient.3 Therefore, a complete evaluation of a patient with lower extremity ulcerations always requires the practitioner to perform a thorough vascular examination.4

What To Look For In The Patient History And Clinical Exam

When assessing patients whom you suspect of having peripheral vascular disease, there are several considerations to be aware of when reviewing the patient history.

   One should note any concomitant medical problems that contribute to a patient’s risk of atherosclerotic disease. Common comorbid conditions include diabetes, hypercholesterolemia, coronary artery disease and cerebrovascular disease among others. In regard to asymptomatic patients with multiple atherosclerotic risk factors, clinicians should routinely screen for involvement of the peripheral vasculature. Ten percent of individuals between the ages of 55 to 74 have asymptomatic lower extremity arterial disease when they are screened.5 Furthermore, atherosclerotic occlusive disease is but one manifestation of a generalized process with affected individuals often presenting with concomitant lesions in a variety of vascular beds such as the coronary, carotid or renal vasculature.6-8

   Clinicians can assess arterial insufficiency based upon a patient’s presenting symptoms. The pain associated with this condition is directly related to the lack of arterial flow to the lower extremity musculature. Symptoms can be acute, chronic or both.

   Patients with acute arterial occlusion from an embolic or thrombotic event may present with an acute onset of increasing pain in the affected limb in the presence of a cool extremity and variable numbness. In the event of an acute event in a patient with known risk factors, these symptoms may be the first signal that arterial insufficiency exists. These acute symptoms can also present in the presence of more chronic complaints in patients with longstanding peripheral vascular disease.

   The patient may complain of pain in the buttocks or calves that is brought on with activity and relieved with rest (intermittent claudication). Patients may experience burning pain in the forefoot that is aggravated by elevation and relieved by dependency (rest pain), or clinicians may note the development of ulceration on the legs, feet or between the toes. Multilevel atherosclerotic disease is usually required to produce significant symptomatology.

   The classical symptoms of claudication or rest pain may be obscured by neuropathy in the patient who has diabetes, and the visual identification of ulcers may be delayed because of associated visual loss from diabetic retinopathy. Elderly patients with significant cardiac or pulmonary disease may not be sufficiently ambulatory to trigger complaints of claudication even though significant disease may be present.

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Anonymoussays: July 8, 2010 at 11:38 am

Great article

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Anonymoussays: November 19, 2010 at 7:32 pm

Nice and useful information.

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