Main complaints
The patient's complaints indicate the nature of the pathological process (venous, arterial, or lymphatic).
- Pain (intermittent claudication). Occurs during walking and subsides at rest. Indicates arterial stenosis or occlusion.
- Muscle weakness. Increases with exertion, typical of arterial disorders.
- Sensory disturbances. Manifest as paresthesias (numbness, tingling) or anesthesia (complete loss of sensation). Typically occur periodically during activity due to insufficient arterial inflow.
- Edema. Indicates impaired venous blood outflow or lymphatic drainage. Can be constant or worsen towards the evening.
Inspection and palpation
Clinical examination reveals obvious changes: varicose veins, edema, trophic disorders.
Signs of arterial insufficiency:
- Pallor, cyanosis, or marbling of the skin (especially significant in the orthostatic test, where pallor is replaced by bluish discoloration upon standing).
- Trophic disorders: dryness, peeling, ulcers, hyperkeratosis, hair loss, nail deformation and thickening.
- Muscle atrophy.
Signs of venous/lymphatic insufficiency:
- Increased limb volume.
- To assess edema dynamics, anthropometry is used — measuring limb circumference at symmetrical levels.
Palpation and auscultation: Skin temperature is assessed by palpation (using the back of the hand). Arterial pulsation must be checked (in the lower extremities: femoral, popliteal, posterior tibial, and dorsalis pedis arteries; in the upper extremities: axillary, brachial, and radial arteries). A systolic-diastolic thrill indicates an arteriovenous fistula, while stone-hard nodules along the veins are phleboliths. Auscultation may reveal a systolic bruit in arterial narrowing.
Functional tests
These tests are relevant in the early stages (compensation stage) before pronounced intermittent claudication develops.
- Oppler's test: the patient lies down and elevates the leg at a 45° angle. The appearance of pallor in the sole within 1 minute (plantar ischemia sign) indicates arterial insufficiency.
- Samuels's test: with legs elevated, the patient flexes and extends the ankles 20–30 times. If the soles turn pale, arterial blood inflow is impaired.
- Moshkovich's test: a tourniquet is applied to the elevated leg of a supine patient for 5 minutes. In obliterating diseases, after its removal, hyperemia occurs with a delay (3–5 minutes instead of the normal 5–30 seconds).
Instrumental methods
Special studies clarify the level of the lesion and the degree of ischemia.
- Oscillography and rheovasography: record a decrease in pulse oscillations and tissue blood filling (rheographic index).
- Thermometry and thermal imaging: register areas of decreased temperature.
- Ultrasound (Doppler sonography): evaluates blood flow, systolic pressure, and venous valve competence.
- Capillaroscopy: reveals spasm, tortuosity, and narrowing of nail fold capillaries.
- Radiopaque methods (angiography, phlebography): visualize stenoses, thrombi, irregular vessel contours in atherosclerosis, or uniform narrowing in endarteritis.
Briefly: answers to topical questions
Where is the dorsalis pedis artery anatomically palpated?
Anatomically, the dorsal artery of the foot (a. dorsalis pedis) is palpated on the dorsum of the foot between the 1st and 2nd metatarsal bones (on the line between the 1st and 2nd toes), located closer to the ankle joint. Its projection, used as an important clinical landmark in assessing peripheral circulation, is determined from the midpoint between the malleoli to the first interdigital space.
How to properly palpate the popliteal artery and where is it projected?
The popliteal artery (a. poplitea) is projected and palpated in the popliteal fossa through adipose tissue. For correct palpation, the patient must be in a prone position. The limb being examined should be flexed at the knee joint at an angle of 120° to ensure maximum muscle relaxation.
What clinical and angiographic features differentiate obliterating atherosclerosis and endarteritis?
The differential diagnosis of obliterating atherosclerosis and endarteritis is based on clinical features and the results of radiopaque examination (arteriography).
| Sign | Obliterating atherosclerosis | Thromboangiitis Obliterans |
|---|---|---|
| Clinical features | Involvement of various vascular beds is typical (multifocal atherosclerosis) | Age 20–40 years, predominantly men (97%), starts in the small vessels of the lower extremities |
| Angiographic findings | Vessels with an "eaten-away" inner contour, areas of narrowing (stenosis) and occlusion | Vessel walls are smooth, with marked uniform lumen narrowing over a long extent |
Class and exam questions
In what position should the popliteal artery be palpated?
The patient should bend the leg at the knee joint to achieve maximum muscle relaxation.
Where is the posterior tibial artery palpated?
It is palpated posterior to the medial (internal) malleolus.
What is the essence of the plantar ischemia sign?
When the leg is raised, the sole quickly turns pale due to insufficient arterial inflow. This is a positive result of Oppler's test.
Do functional tests have diagnostic value in late stages?
In the subcompensation and decompensation stages, the tests lose their significance, as a prominent clinical symptom—intermittent claudication—comes to the foreground.
What else to study on this topic
- Technique of thermometry and infrared thermography
- Features of arteriography in obliterating endarteritis and atherosclerosis
- Application of radioisotope diagnostics (scintigraphy) of vessels
- Assessment of the functional state of vessels using the nitroglycerin test
- Auscultation points for major arteries
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