The visit of the vascular patient

Update for the practical doctor

notes by dott. Claudio Italiano

Clinical examination of the peripheral arterial system

Cf also esame fisico delle arterie

Whatever the location and nature of the arterial disease, the examination of the vascular system must always be complete.

 It also includes, of course, the heart, which we exclude from our study.
We will only deal with arterial diseases of the limbs.

The obstructive arteritis (see vasculitis) is the most frequent.

The same conditions can affect the visceral arteries; in this case they take on particular aspects depending on the interested organ.

With the anamnesis of the patient we investigate the existence of pains - from stress or decubitus - especially at the calf, to inquire about a possible arteritic heritage or smoking. The appearance of the limb can provide important elements on its circulatory status:

Skin coloring: rosy, normal; pale or cyanotic; pigmented.

Trophy of the skin: spots, flittene, ulcerations.

Trophy of nails, hair: rare, fragile.



Muscle tropism: amyotrophy.

Comparative local temperature; as needed, skin thermometry.

The examination of the vascular system of the limbs must always be symmetrical and comparative.

The pulse palpates:

In the upper limb:

- in the wrist shower (radial artery);

- at the bend of the elbow in the internal bicipital furrow (humeral artery).

 On the lower limb, after the palpation of the abdominal aortic beats and the iliac arteries, wrist scan:

- Femoral: at the center of the crural arch;

- Poplitis: in the axis of the popliteal flexed knee;

- posterior tibial artery: in the internal retromalleolar shower;

- dorsalis pedis artery: in the middle of the back of the foot.

A slight, systolic murmur is normal at listening to the arteries. A more rude, harsh breath indicates an arterial stenosis. Measurement of arterial pressure in the upper limb with the Vaquez apparatus.

The stethoscope, located at the elbow, on the humeral beam, detects the pulsations. The inflated cuff suppresses the arterial flow downstream. When the pulsations reappear, as the cuff progressively deflates, the needle indicates the maximum systolic blood pressure; when the intensity of the pulsations decreases abruptly then the needle marks the minimum diastolic arterial pressure.

The figures correspond to the pressure in millimeters of mercury: Normal: 130-80 mmHg (see hypertension). The relief of the oscillations and blood flow of the vessels is obtained thanks to the ecocolordoppler investigation which, in general, is carried out on the epiaortic vessels or the lower limbs. In the other cases it makes use of the angio-CT or angio-NMR examination.

Arteriography can be practiced in all vessels.

This examination consists in the injection of an iodinated contrast medium into an artery, or into a group of arteries, to opacify them and then perform some X-rays thanks to an apparatus, the intensity intensifier. The latter allows to follow the opacification live and to make repeated snapshots very quickly.

arteriografia bilaterale in paziente con arterite obliterante: vaso stenotico (freccie)

Arteriography, obstructive arteriopathy

It's a disused technique, since the only concrete indication is the exploration of the vessels before intervening with the angioplasty and by-pass interventions (see revascularization of the lower limbs).

From the time of the development of other less aggressive exploratory techniques of ultrasound, the doppler, the computerized angiography);  the arteriography of the lower limbs is prescribed less often as a first examination. However it allows to study arteries and their branches precisely. We describe femoral arteriography and aortography.

-The femoral arteriography is performed, with a common syringe, by direct puncture below the crural arch; the radiograms are taken in series (seriography).

-The aortography gives details on the terminal branches of the aorta, on the iliac arteries and on the arteries of the lower limbs.

■ Two methods:

■ For direct injection:

Sick prone. Postero-lateral puncture of the aorta. A technique similar to the previous one, but instead of the syringe, a pneumatic device can be used which injects the iodized solution more rapidly.

■ For retrograde catheterization (Seldinger).

Sick on the back. Ascending introduction of a catheter through puncture of the femoral artery. This method assumes the patency of a femoral artery and the vascular wall not too much altered in order not to cause an aggravation of the lesions.

It is equally possible, by appropriately orientating the catheter, to perform selective visceral arteriographies.

index  vascular disease