Arterial Occlusion, Part 2: Evaluation

Arterial Occlusion, Part 2: Evaluation Posted By:
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The initial evaluation of a patient with suspected arterial occlusion begins with the physical exam. Start by observing the patient's gait if they are ambulatory. Then assess for changes in temperature along the affected extremity and compare it with the other limb. Bilateral extremity pulse exams should be conducted with manual palpation; if/when you note a deficient pulse, include a handheld arterial Doppler exam (if available). You may also auscultate for vascular bruits, particularly in the femoral arteries; have another provider check to confirm your suspicions if necessary. In addition, muscle strength and sensation testing should be done. When occlusion has been identified, duplex ultrasonography should be obtained to evaluate the patient's vascular status. Ultrasound imaging has the advantage of being noninvasive and requiring no contrast media or radiation, though it is highly technician dependent.

In general, suspect severe ischemia if there is an absence of any distal Doppler signals (arterial or venous). If you are able to discern Doppler signals, an ankle-brachial index (ABI)—which compares the blood pressure in the upper and lower limbs—should be obtained. In the lower extremity, the location of the thrombus or embolus may cause ABI to vary significantly, but a value <0.4 always indicates severe ischemia. In all the facilities I work in, the score will be incorporated into the ultrasound results. The ABI scoring system is as follows:

  • 1.0 to 1.4 – Normal
  • 0.9 to 1.0 – Borderline
  • 0.7 to 0.9 – Mild
  • 0.4 to 0.7 – Moderate
  • <0.4 – Severe

In addition to the above, the most common examination findings suggestive of lower extremity peripheral artery disease include:

  • Intermittent claudication
  • Ischemic pain at rest
  • Lower extremity gangrene
  • Nonhealing lower extremity wound
  • Pallor on elevation of the legs or dependent rubor

You may also note hair loss, shiny skin, muscle atrophy, or arterial ulcerations—which appear as well-demarcated, "punched-out" lesions.

A vast majority of providers perform adequate to perfect exams, yet they fail to document this in the medical chart. This may lead to increased doubt if there is a poor outcome and the patient decides to litigate for delayed or missed diagnosis. I try to emphasize to all students that their documentation will save them one day, yet I see seasoned providers still making rookie mistakes. I recommend that when examining patients' extremities, you document the following (not all inclusive):

  • Tenderness
  • Deformity
  • External skin appearance and warmth, edema
  • Decreased muscle strength or tone (eg, flaccid, atrophy)
  • Decreased sensation
  • Limited range of motion and/or abnormal movements
  • Gait changes (eg, antalgic gait), ability to bear weight
  • Perfusion (eg, sluggish capillary refill, bounding pulses, diminished or absent pulses)

An example of an adequate extremity documentation:

Upper and lower extremities are atraumatic in appearance without tenderness or deformity. No swelling or erythema. Full range of motion is noted to all joints. Muscle strength is 5/5 bilaterally. Skin is warm and dry. Capillary refill is less than 3 seconds in all extremities. Strong/bounding pulses palpable bilaterally/equally. Steady gait noted.

References
  • Firnhaber J, Powell C. Lower extremity peripheral artery disease: diagnosis and treatment. Am Fam Physician. 2019;99:362.
  • Khan NA, et al. Does the clinical examination predict lower extremity peripheral arterial disease? JAMA. 2006;295:536.
  • Smith D, Lilie C. Acute arterial occlusion. In: StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing; 2021.

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Filed under: Cardiometabolic

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