The procedure for conducting a thorough vascular assessment consists of three steps: a medical history focusing on vascular- related events, a targeted physical examination, and specifi c vascular testing.
Past Medical History
Exhibit 6.1 lists areas of the medical history used to identify risk factors for vascular disease, both arterial and venous. Notice that it goes beyond the general medical history discussed in Chapter 1 and focuses on specifi c vascular-related events. The medical history should include questions about diagnoses of peripheral vascular disease (PVD), atherosclerotic cardiovascular disease, diabetes mellitus, renal disease, prior deep vein thrombosis, varicose veins, chronic venous insuffi ciency, and elevated cho- lesterol and triglycerides. A thorough surgical history should include all previous operations, especially vascular proce- dures, including peripheral arterial and venous procedures.
Cardiac procedures should also be included, because the greater
saphenous vein is often utilized for bypass procedures. This can cause signifi cant wounds, especially in the diabetic population, and can aggravate any long-standing venous insuffi ciency.
It is also essential to review the patient’s use of medications.
Especially signifi cant are the use of steroids, rheologic agents, antihypertensive medications, anticoagulants, antiplatelet agents, and aspirin.
Critical evaluation of the patient’s symptoms can help you distinguish the cause of the wound. In the patient with sus- pected arterial problems, pay attention to reports of pain, including the following:
• Claudication. Typical claudication (from the Greek for “to limp”) is pain in the calf upon walking some distance. It is due to inadequate perfusion to the calf muscles. The pain rap- idly diminishes after the activity is stopped. If this symptom disappears for long periods of time or if the pain is helped by positional changes, a neurologic cause, such as spinal stenosis or disk problems, should be entertained. This is the so-called pseudoclaudication or neuroclaudication.
• Rest pain. Rest pain is pain across the forefoot, mainly associ- ated with positional elevation. It occurs with inadequate blood supply to the foot. Patients may state that, to relieve the pain at night, they will “hang” their feet over the side of the bed. This enables gravity to increase blood fl ow, thus relieving pain.
• Fatigue and/or swelling. Often patients with vascular disease will experience a sensation of “tiredness” in the limbs. They may also experience swelling that increases during the day or during long periods of standing.
With female patients, elicit an obstetrical history focusing on the development of varicosities during pregnancy. The varicosities At the completion of this chapter, the reader will be able to:
1. Identify the areas of the medical history and the physical examination techniques important for assessing patients for vascular disease.
2. Compare and contrast techniques for noninvasive arterial testing.
3. Explain the technique for obtaining an ankle brachial index.
4. Describe the most common type of invasive arterial study.
5. Discuss the physiologic and anatomic tests for evaluating venous insuffi ciency.
Gregory K. Patterson
6
Sussman_Chap06.indd 173
Sussman_Chap06.indd 173 7/25/2011 2:37:20 PM7/25/2011 2:37:20 PM
EXHIBIT 6.1
Past Medical History
Risk Factors for Peripheral Vascular Disease1 Cardiac history
● Heart disease (cardiac catheterization? results?)
● Heart attack (date of last event)
● Chest pain (note location of the pain, how is pain relieved?
onset?)
● Stroke (date of event, note location of weakness or speech defi cit)
Hypertension (severity, medications, age at onset, highest blood pressure reading)
Hyperlipidemia (last cholesterol level, medication, number of years)
Smoking history (number of packs per day × years smoked = number of pack-years) (For example: a patient smoking two packs per day for 20 years has a 40-pack-year smoking his- tory.) (quit? year quit)
Diabetes (number of years, medications)
Concomitant illnesses (renal disease, collagen vascular dis- ease, arthritis, pulmonary disease, malignancy [type of malignancy], back [spine] problems, etc.)
Family history of arterial disease Risk Factors for Venous Disease Trauma (type, date)
Deep vein thrombosis (date, anticoagulants) Prolonged inactivity or standing activity Multiple pregnancies
Family history of venous disease or varicose veins Obesity
Clotting disorders Past Surgical History
Vascular surgery (date of procedure, indication) Angiogram/venogram (dates, indication, intervention?) General surgery (date of procedure, indication)
Arterial Insuffi ciency Venous Insuffi ciency
Pain Intermittent claudication. May progress to rest pain;
chronic, dull aching pain. Progressive throughout the day.
Color Pale to dependent rubor, a dull to bright, reddish color.
More common with advanced disease.
Normal to cyanotic. More common with advanced disease.
Skin temperature Poikilothermic, taking on the environmental temperature.
Much cooler than normal body temperature.
Usually no effect on temperature.
Pulses Diminished to absent without Doppler stethoscope. Usually normal. May be diffi cult to palpate.
Secondary to signifi cant edema.
Edema Usually not present unless combined disease or can be related to cardiac disease and congestive heart failure.
Present from mild to severe pitting edema. Can have weeping edema fl uid from open wounds.
Tissue changes Thin and shiny. Hair loss. Trophic changes of the nails.
Muscle wasting.
Stasis dermatitis with fl aky, dry, and scaling skin.
Hemosiderin deposits—brownish discoloration.
Fibrosis with narrowing of the lower legs, “bottle legs.”
Wounds Distal ulceration, especially on toes and in between in the web spaces. May develop gangrene and severe tissue loss.
Shallow ulcers in the gaiter distribution of the foot and ankle, usually the medial surface.
Comparison of Arterial and Venous Disease 6.1
TABLE
occur secondary to the effect of high levels of estrogen on the vein walls or pelvic congestion from the gravid uterus “press- ing” on the iliac veins.
Physical Examination
The general physical examination is extremely important for patients with suspected or known vascular disease. It includes techniques of inspection, palpation, and auscultation that can
help you identify objective signs of vascular insult. To perform the examination and interpret the fi ndings appropriately, you need a thorough understanding of the anatomy and physiology of the cardiovascular and lymphatic systems. Use Table 6.1 to help you differentiate between inspection and palpation fi ndings due to arterial insuffi ciency and those due to venous insuffi ciency.
Inspection should include the size and symmetry of the limb in question. Compare it with the contralateral limb.
Sussman_Chap06.indd 174
Sussman_Chap06.indd 174 7/25/2011 2:37:20 PM7/25/2011 2:37:20 PM
Observe for edema or swelling. Check the color and texture of the skin, including the nail beds and capillary refi ll. Also assess for the absence of hair, which is highly suggestive of arterial disease, and for muscle wasting. Determine the over- all venous pattern, and document the presence and location of all varicose veins. Scars, rashes, and pigmentation changes, such as hemosiderin deposits seen in chronic venous insuf- fi ciency, should be noted.
The palpation step of the physical exam begins with palpa- tion of all major pulse points. Palpate the radial and brachial pulses in the arm, the carotid pulse in the neck, and the femoral pulse in the groin (Fig. 6.1). Although the popliteal pulse can be diffi cult to assess, you should check it routinely, as a bounding popliteal pulse could indicate popliteal artery aneurysm. The popliteal pulse can be assessed from an anterior approach with the patient supine (Fig. 6.2); however, it is easier to palpate with the patient in the prone position, using the posterior approach (Fig. 6.3). The dorsalis pedis and posterior tibial arteries are also assessed (Figs. 6.4 and 6.5).
Auscultation includes assessment for any audible harsh sounds, called bruits. This can be done with a regular stetho- scope and is performed typically over the larger vessels, the carotids, the aorta, renal arteries, and iliac arteries. Auscultation for bruits occurs after palpation of the pulses. The bell of the stethoscope is placed over the artery, and you should listen for a blowing or rushing sound. A bruit may be a sign of arterial
CLINICAL WISDOM
Trophic Changes
Trophic changes are skin changes that occur over time in patients with chronic arterial insuffi ciency. Trophic changes include absence of leg hair; shiny, dry, pale skin; and thick- ened toenails. These symptoms are due to the chronic lack of nutrition from an inadequate blood supply to the extremity.
Some of these changes occur naturally in elderly patients.
CLINICAL WISDOM
The pulse exam includes locating and grading bilateral femoral, popliteal, dorsalis pedis, and posterior tibial artery pulses. The following system should be used to grade pulses:
● 0 = No pulse
● 1+ = Barely felt
● 2+ = Diminished
● 3+ = Normal pulse (easily felt)
● 4+ = Bounding, aneurysmal (“pulse hits you in the face”)
FIGURE 6.1 Palpation of femoral artery. (Courtesy of Archbold Wound Care Center, Thomasville, Georgia.)
narrowing. Finally, assessment of any visible wounds should be completed as with all wound patients (see Chapter 3).
Vascular Testing
If fi ndings from the standard history and physical suggest that further investigation of a patient’s vascular status is needed, vas- cular testing should be obtained. Many vascular tests are non- invasive, using some form of external imaging or measurement method to gather data on the structure and functioning of the vessels in a given region. The most commonly used noninvasive techniques employ ultrasound and its many derivatives. As part of your vascular evaluation, you should be prepared to conduct a variety of noninvasive tests.
Other vascular evaluation techniques are invasive; they are performed by vascular labs or radiology departments and may be recommended if noninvasive testing indicates problems that require more in-depth examination. Those involving injection of contrast media and data acquisition, usually in the form of radiographs, are the most commonly employed.
As a wound care professional, you should become famil- iar with the various tests, their benefi ts, and their limitations.
These are the subject of the remainder of this chapter. We fi rst discuss noninvasive tests of the arterial system. We then discuss briefl y the invasive tests—mainly angiography—that require the care of a vascular surgeon. We then explore tests conducted to evaluate chronic venous insuffi ciency.
FIGURE 6.2 Palpation of popliteal artery (anterior approach). (Cour- tesy of Archbold Wound Care Center, Thomasville, Georgia.)
Sussman_Chap06.indd 175
Sussman_Chap06.indd 175 7/25/2011 2:37:20 PM7/25/2011 2:37:20 PM
embedded in a handheld probe (Fig. 6.6). The crystal emits a sound wave that is refl ected by the red blood cells traveling in the vessel of interest. This sound wave is refl ected back to the probe and is transformed into an audible signal, which you can evaluate subjectively or record on a graphic analyzer.
The continuous wave Doppler gives us a phasic fl ow pat- tern. The normal fl ow is triphasic: The fi rst sound represents forward fl ow during systole. The second sound represents a reversal of fl ow during diastole. The third and smallest sound represents a return of forward fl ow, caused by elastic recoil of the artery. As vascular disease progresses, this triphasic fl ow diminishes to a biphasic fl ow. This is due initially to the loss of elastic recoil caused by “hardening” of the arteries. If the dis- ease progresses further, the fl ow will decrease to a monophasic signal; that is, the fl ow will lose its pulsatile nature altogether (Fig. 6.7).
The phasic fl ow patterns are mainly a subjective test in which the data are interpreted in a subjective manner by the clinician.
When we apply a blood pressure cuff and occlude the fl ow in the artery, and then use the Doppler to access the return of fl ow as the pressure is decreased in the blood pressure cuff, we have obtained a Doppler blood pressure. In vascular assessment,