Vascular Patient Assessment

Approach to the Vascular Patient

• Timing is crucial when taking history from vascular patients
• History should include: pain, weakness in extremities, neurosensory complaints (warmth, numbness, hypersensitivity), discoloration, swelling, tissue loss/ulceration, varicosities
• Medical history should include: hypertension, atherosclerotic disease (CAD, PAD, CVA, carotid stenosis), hyperlipidemia, diabetes mellitus
• Surgical history should be thoroughly reviewed
• Social history: smoking is a major risk factor
• Meticulous inspection and documentation of skin changes should be performed during physical exam
• Palpate pulses unilaterally (abdominal aorta), and bilaterally (carotid, brachial, radial, ulnar, femoral, popliteal, posterior tibial, & dorsalis pedis arteries)
• Auscultation for carotid & renal bruits (indicative of turbulent flow)
• Screening ultrasound for abdominal aortic aneurysm (AAA)
• Follow-up ultrasound for patients with known or suspected vascular disease or those who underwent vascular intervention

Pulse Examination Locations

• Femoral: midway between ASIS and pubic tubercle
• Popliteal: popliteal fossa, knee at 45° angle, with two hands
• Posterior tibial: 2 cm posterior to medial malleolus
• Dorsalis pedis: 1 cm lateral to extensor hallucis longus tendon
• Always compare sides

Arterial Disease

• Aorta:
  • Aneurysm: dilation that can lead to rupture
  • Dissection: intimal tear leading to a false lumen
• Peripheral arteries: typically affects limbs
  • Peripheral artery disease (PAD)
  • Aneurysm: most common in popliteal artery, followed by femoral artery
• Extra-cranial cerebrovascular arteries:
  • Carotid stenosis
  • Vertebral artery compression
• Visceral arteries: renal, splanchnic, & mesenterics
  • Stenosis, occlusion, aneurysm, vasculitides

Peripheral Arterial Disease (PAD)

• Obstruction or deterioration of arteries other than those supplying the brain or the heart
• Commonly affects the lower extremity
• Major pathophysiologic process is atherosclerosis
• Patients typically present with claudication: pain with activity, that is relieved by rest, and reproducible with the same level of activity
• May present with non-healing wound
• Affects 20% of Americans ≥65 years old
• Increased risk with: obesity, non-white ethnicities, smoking, diabetes, HTN and HLD (same risk factors as atherosclerosis)

Pseudoclaudication

• Leg pain caused by nerve impingement (spinal stenosis) rather than arterial obstruction
• Aka neurogenic claudication
• Variable walking distances
• Positional relief (leaning forward)

Diagnosis of PAD – Ankle-Brachial Index (ABI)

• Ratio of ankle pressure to systemic (brachial) pressure
• BP cuff is inflated until pulse becomes inaudible via doppler
• Perform at posterior tibial, dorsalis pedis and brachial arteries
• Use the highest brachial pressure overall (systolic), and the highest ankle pressure per limb

This quiz focuses on the critical approach needed when evaluating vascular patients. It covers essential topics like taking patient history, performing physical exams, and understanding the significance of various medical and surgical histories. Key components such as inspection, palpation, and auscultation techniques are also included.