Clinical Evaluation of the Arterial System

This chapter focuses on the role of patient history and physical examination in evaluating the various disease states secondary to arterial pathology. In general, the lower extremities provide a model for the clinical evaluation of patients with vascular disease and can be used to demonstrate the value of an organized approach to the history and physical examination of the patient.

Overview of the Clinical Evaluation

The patient’s chief complaint should be determined; the physical examination should be correlated with the history and should provide a bridge to the pathophysiology of the disease process. ^, As an example, aortoiliac obstructive disease will often be associated with more proximal symptoms of claudication involving the buttock, hip, or thigh. If the clinical history is accurate, the examiner should expect that the femoral pulse will be absent or decreased. If it is not, the history and assumptions regarding pathophysiology should be questioned.

When the history and physical examination are completed, diagnostic studies can be ordered, if necessary, to further localize the disease or quantify the extent of the process. Therapy is ultimately driven by the natural history of the disease process and its impact on quality of life, as well as by the patient’s risk factors and functional status. A relatively benign natural history or significant and unmodified patient risk factors may indicate an initial course of medical management, risk factor modification, and observation, whereas a threat of tissue loss may indicate the need for a more aggressive intervention.

Clinical History

Typically, the symptoms of arterial disease can be broadly classified into the following categories: pain; weakness; neurosensory complaints, including warmth, coolness, numbness, and hypersensitivity; discoloration; tissue loss and ulceration. Critical elements include the initial onset of symptoms (acute or chronic); progression or changes since the initial onset; location (unilateral, bilateral, proximal, distal); character or quality of the symptom or complaint; some measure of the extent of disability or limitation; the context or factors precipitating or aggravating the symptoms (activity, position, temperature, menses, vibration, pressure); factors mitigating or relieving symptoms; and associated signs, symptoms, or risk factors. In the assessment of vascular disease, the history is important. As will be seen, variations from the expected history or pattern of findings may suggest additional disease processes that might be included in the differential diagnosis.

Physical Examination

The physical examination links the clinical history and the pathophysiology of the arterial disease process. The pathology associated with arterial disease can be broadly classified into inflammation-mediated arterial wall changes, arterial wall irregularity or ulceration, stenosis/occlusion, and dilation and aneurysmal degeneration, in contrast to the pathophysiology of venous and lymphatic disorders. ^,

The physical examination should progress from inspection, to palpation, to auscultation. On inspection, the extremity should be assessed for evidence of skin changes, including atrophy, cyanosis or mottling, pallor, and rubor; hair distribution; and abnormalities in nail growth. The presence and location of edema should be identified and quantified. Tissue loss and ulceration should be noted and fully described, including the location, size, and depth, and the presence of associated cellulitis and inflammation should be documented. Motor function should be documented. On initial palpation, changes in temperature and sensation should be noted and compared with the contralateral extremity. All accessible pulses should be evaluated. At a minimum, pulses should be classified as absent, decreased, or normal. A prominent or widened pulse may suggest aneurysmal degeneration.

Synthesis of History and Physical Examination

Assessment of a patient with arterial disease is unique in that it is frequently possible to make a diagnosis and predict the underlying anatomic pathology on the basis of history and physical examination alone. This is important because the anatomy of the disease process can often correlate with the location of symptoms. The history and physical examination should be thought of as a system of checks and balances. Symptoms should correlate with the physical examination and suspected pathology.

The Evolving Role of Telemedicine in the History and Physical Exam for Vascular Disease

As with many aspects of healthcare, technology has changed the landscape in which we practice. Many fields rely heavily on remote interaction between treating physicians and their patients. While many believe that telemedicine in vascular surgery is a new and evolving concept, it has been studied for more than 20 years (see Ch. 204 , Telemedicine in Vascular Surgery Practice). For example, Endean and colleagues described vascular evaluation by teleconference, remote Doppler assessment, and the use of physician extenders in a manuscript published in 2001. ^, The barriers they described at the time sound strikingly familiar to the challenges we all face, and electronic health records today comfort with technology and successful execution of technology-based assessment strategies. While this is an evolving strategy, future advances will undoubtedly change the way we perform physical examination in the future.

For many healthcare providers, changes incurred by the coronavirus pandemic in 2020 spurred on a rapid adoption of telemedicine. Billing processes were rapidly changed to allow healthcare providers to expand the use of telehealth, and guidelines from the Centers for Disease Control and Prevention encouraged healthcare providers and patients to use telehealth during the pandemic whenever possible. Figure 19.1 shows the locations in the United States where billing legislation allowed implementation of telehealth visits. While many visits with patients with vascular disease could readily transfer to telehealth, such as assessment for abdominal aortic aneurysm using cross-sectional imaging, there are other aspects of history and physical – frailty assessment, pulse exam, and patient counseling – that may fare better using in-person visits. The pandemic undoubtedly accelerated this tool, which will certainly remain in use for years to come.

Figure 19.1, Locations where Telehealth Legislation Allows Remote Visits.

Documentation and billing aspects, as well as technology for pulse assessment, are a rapidly evolving field, and will certainly progress to help keep vulnerable patients at home whenever remote assessment is allowable.

History in Patients With Arterial Disease

Patients with peripheral arterial disease (PAD) may initially be seen after acute arterial occlusion or with symptoms of chronic arterial insufficiency. Regardless of whether the onset of symptoms is acute or chronic, the chief complaint is generally pain or discomfort. As part of the initial history, it is important to determine the acuteness of onset, the character and intensity of the pain or discomfort, changes in the character and intensity since onset, and its location.

Acute Arterial Occlusion

Acute arterial occlusion may be either embolic or thrombotic in etiology (see Ch. 103 , Acute Limb Ischemia: Evaluation, Decision-Making and Medical Treatment). Classically, acute arterial occlusion is associated with the six Ps: pain, pallor, pulselessness, paresthesias, paralysis, and poikilothermy (meaning changing to room temperature; i.e., a cold extremity). Symptoms can occur within minutes to hours after acute arterial occlusion and are associated with a sudden, dramatic decrease in perfusion. Classically, a patient will complain of generalized pain, severe, and not well localized. The patient will notice a change in the color of the extremity, a decrease in sensation, and coolness to touch. Absent motor function is consistent with severe limb-threatening ischemia.

Acute Arterial Occlusion of the Lower Extremity

As a rule, patients with acute arterial occlusion secondary to an embolic etiology will not have a history of claudication or symptoms suggestive of chronic occlusive arterial disease. Embolic occlusion of the iliac, femoral, or popliteal arteries is frequently associated with a history of atrial fibrillation, and the patient may have had a previous embolic event. Patients with thrombotic occlusion of the iliac, femoral, or popliteal arteries will frequently have a history of claudication and may have previously undergone arterial bypass or intervention.

Atheroembolism: “Blue Toes Syndrome”

Atheroembolic debris arising from atherosclerotic plaque or ulcerations in the aorta, as well as the iliac, femoral, and popliteal arteries, can result in distal small-arterial occlusion (see Ch.106 , Atheromatous Embolization and Its Management). Progressive renal insufficiency can be associated with atheroemboli originating in the thoracic or suprarenal aorta. Patients may have undergone some form of catheter-based procedure involving manipulation of a catheter in the aortic arch or the thoracic and abdominal aorta, or the embolism may be spontaneous.

Acute Arterial Occlusion of the Upper Extremity

While less common, acute arterial occlusion may also occur in the upper extremities. The onset and symptoms are similar to those seen in the lower extremities. Emboli associated with atrial fibrillation or recent myocardial infarction are more common, but may also originate from aneurysmal disease of the arch or upper extremity arteries. Atheroemboli involving the hand or digits may arise from atherosclerotic irregularity and plaque in the aortic arch, or from thrombus associated with a subclavian artery aneurysm.

Chronic Obstructive Arterial Disease

Patients with PAD most commonly have long-standing symptoms. Chronic PAD can be categorized according to the Rutherford classification system of occlusive arterial disease, which encompasses a spectrum of symptoms, beginning with effort discomfort (claudication) and progressing to pain at rest and tissue loss. Claudication is derived from the Latin word claudicare , which means to limp or be lame. Thus, claudication involves the lower extremities and is associated with walking. Effort-induced discomfort with activity involving the upper extremity can be associated with stenosis or occlusion of the subclavian and axillary arteries. The Rutherford classification system – a clinical staging system – ranges from asymptomatic (stage 0), to mild or moderate claudication (stage 3), to severe (stage 6). ^,

Lower Extremity Claudication

Claudication symptoms are associated with walking, and relief occurs promptly after the cessation of activity. Complete relief of symptoms should occur within 5 to 10 minutes, and it should not be necessary for the patient to sit to obtain relief. Symptoms may be described as cramping, aching, fatigue, or numbness, and the common denominator is an association with exercise or activity.

Symptoms may have been present for months or years. Anatomically, lower extremity PAD is broadly classified as aortoiliac, femoropopliteal, or tibial. Depending on the location of the arterial obstruction, the patient may have pain in any of the three major muscle groups of the lower extremity: the buttock, thigh, or calf. Symptoms may involve one or more of these muscle groups and may progress from the proximal to the distal part of the extremity or from the calf to the thigh with continued activity. Symptoms will often occur in the muscle group immediately distal to the obstruction. Whereas obstruction of the superficial femoral artery will cause calf discomfort, aortoiliac disease will result in symptoms involving the buttock or thigh. However, patients with aortoiliac disease can also have associated or isolated discomfort of the calf because the calf is the most distal large muscle group and is used extensively in walking. The triad of intermittent claudication, impotence, and absent femoral pulses is associated with aortoiliac occlusion and is often referred to as Leriche syndrome. In his initial descriptions of the disease process, Leriche also identified widespread atrophy of the lower extremities and a pale appearance of the extremities and foot.

Some patients with PAD confirmed by noninvasive vascular testing may not complain of claudication because comorbid conditions may limit their exercise tolerance. Conversely, other patients may have classic symptoms of claudication but a normal pulse examination. Because initial assessment generally occurs while the patient is at rest on the examining table, it is important to remember that the claudication occurs with walking. In cases when there is a mismatch between the history and physical examination, the physical examination may need to be repeated after exercise.

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