Visual assessment and trophic changes
Patient inspection begins with evaluating skin color and its appendages. Chronic arterial insufficiency typically manifests as subcutaneous fat atrophy, skin thinning, hair loss, and nail deformity. Tactile sensitivity is also reduced. A postural test can be performed to check this: when the limb is elevated, it rapidly turns pale or acquires a bluish tint. Upon lowering, reactive hyperemia occurs—the skin becomes crimson-cyanotic.
Special attention is paid to paroxysmal color changes in the fingers of the hands (most commonly digits IV and V), which are characteristic of Raynaud's syndrome. Under the influence of cold or stress, the fingers first turn extremely pale due to severe spasm, then cyanotic, and upon warming and vasodilation—intensely red. This process is accompanied by pain and paresthesias.
Sometimes hemodynamic disturbances are noticeable even at a distance. For example, prominent visible pulsation of the carotid arteries and rhythmic head bobbing synchronous with the pulse (de Musset's sign) indicate high pulse pressure. Most commonly, this is seen in aortic valve regurgitation or severe atherosclerosis in elderly patients.
Palpation of arteries
The main rule of palpation is the mandatory comparison of the pulse in symmetrical areas on both sides. A sharp weakening or absence of the pulse in the legs combined with complaints of intermittent claudication (calf pain during walking that resolves at rest) indicates chronic ischemia. The reason is that at rest, the narrowed vessel is sufficient for tissue nutrition, but under exertion, an oxygen deficit occurs.
Main palpation points on the foot:
- a. tibialis posterior (posterior tibial artery) — palpated behind the medial malleolus.
- a. dorsalis pedis (dorsalis pedis artery) — located proximal to the interdigital space, near the tendon of the extensor hallucis longus.
During an abdominal examination, a healthy abdominal aorta is usually not accessible to palpation. The presence of a pulsatile mass slightly to the left of the midline requires ruling out an aneurysm. However, in patients with low body weight and a thin abdominal wall, the aorta may be palpable normally; therefore, verification of the diagnosis always requires ultrasound or CT.
If an aneurysm ruptures, the clinical picture changes rapidly: a coarse systolic bruit appears, severe back or abdominal pain occurs, blood pressure drops, and pulsation in the peripheral vessels of the legs disappears. Early diagnosis and examination save lives by preventing this fatal scenario.
Auscultation of major vessels
Auscultation of arteries helps find stenoses (narrowings). When the vascular lumen narrows, blood flow becomes turbulent, and a systolic bruit occurs. It is important to apply the stethoscope gently, without pressure. If the artery is completely blocked (occlusion), the bruit disappears due to the absence of blood flow.
Key auscultation points:
- Carotid arteries (along the medial border of the sternocleidomastoid muscle) — to detect the risk of cerebral ischemia.
- Renal arteries (just above the umbilicus, lateral to the midline) — their narrowing is a cause of renovascular hypertension.
- Subclavian and femoral arteries.
Normally, natural tones can be heard over large vessels. The first tone results from the stretching of the vessel wall by the pulse wave, and the second tone is transmitted and results from the closure of the aortic and pulmonary valves.
Examination of the venous system
Unlike arteries, examination of the venous system focuses on identifying two other pathological mechanisms:
- Blood flow obstruction. Occurs during thrombus formation, development of phlebitis, or external compression of the vein.
- Valvular insufficiency. Characteristic of patients with varicose veins.
Briefly: answers to topical questions
Which clinical tests are used to assess the competence of superficial vein valves in the lower extremities?
For clinical assessment of the valvular apparatus of the lower extremity veins, digital and tourniquet tests are used. Normally, perforating vein valves ensure blood flow in only one direction — from superficial veins to deep ones. With functional valve insufficiency (during muscle contraction), pathological blood reflux occurs back into the superficial veins, provoking their varicose dilation. Additionally, instrumental diagnostics including rheography, dopplerography, contrast phlebography, and infrared thermography are used to accurately assess valve status.
Which tests are used to assess deep vein patency in the lower extremities?
Deep vein patency in the lower extremities is assessed using the functional march test. Patients with deep vein obstruction do not tolerate elastic compression.
The procedure involves the following stages:
- applying a tourniquet to the thigh in a horizontal position;
- bandaging with an elastic bandage up to the upper third of the thigh;
- walking for 20–30 minutes.
The appearance of bursting pain indicates deep vein obstruction. Instrumentally, phlebography provides the most complete information about the state of venous blood flow and deep veins.
At which points is palpation of the major upper extremity arteries performed?
Palpation of the major upper extremity arteries is performed at the following points:
- Axillary artery.
- Brachial artery (a. brachialis) — in the medial sulcus of the arm; the pulse is also palpated at the level of the medial epicondyle at the inner edge of m. biceps brachii.
- Radial artery (a. radialis) — at the lateral edge of the wrist, 0.5–1 cm lateral to the tendon of m. flexor carpi radialis; the artery lies directly on the radius.
- Ulnar artery (a. ulnaris) — in the ulnar canal of the wrist at the lateral edge of the pisiform bone, where its pulsation is determined.
To memorize the phases of skin changes in Raynaud's syndrome, use the color sequence of the Russian or French flag: white (pallor from spasm), blue (cyanosis), red (reactive vasodilation and hyperemia).
Class and exam questions
Why does pain occur only during walking in intermittent claudication?
At rest, the narrowed arterial lumen is sufficient to supply the calf muscles with blood. During physical exertion, the tissue demand for oxygen increases sharply, and the stenosed vessel cannot cope, causing painful ischemia.
What does de Musset's sign indicate during visual inspection?
De Musset's sign (rhythmic head bobbing in time with the heartbeat) indicates high pulse pressure due to a low diastolic component, which is most characteristic of aortic valve regurgitation.
Does pulsation in the abdomen always mean an abdominal aortic aneurysm?
No, not always. In thin patients with a thin abdominal wall, aortic pulsation may be palpable normally. Instrumental confirmation (ultrasound or CT) is necessary for an accurate differential diagnosis.
What else to study on this topic
- Acute arterial insufficiency and high risk of gangrene development
- Differences between primary Raynaud's disease and secondary Raynaud's syndrome
- Topography of auscultation for all major peripheral vessels by points
- Clinical picture and hemodynamics in abdominal aortic aneurysm rupture
- Postural tests to assess the adequacy of lower extremity blood flow
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