Peripheral Arterial Examination
A complete physical examination includes systematically assessing the peripheral
arteries. For example, by starting at the head, and working downwards. The
examination includes palpating pulses and auscultating for possible bruits.
If starting in the head and neck area, palpable pulses include the superficial
temporal artery of the head, the common carotid artery medial to the
sternocleidomastoid muscle, and the subclavian artery posterior to the
clavicula.
There are some important things to remember when palpating the carotid.
Compressing both sides of the artery too strongly or over stimulating the carotid
sinus reflux can cause cerebral hypoperfusion and consequently syncope.
So palpation should only be done with minimal pressure and never on both sides
simultaneously. In contrast, palpating the subclavian
pulse on both sides may be done at the same time.
For assessing pulses of the upper extremities, there is the radial artery
on the lateral anterior surface of the forearm and the ulnar artery on the
medial side. Additionally, the brachial artery can be
palpated proximal to the cubital fossa. The radial artery can be palpated with
the second to fourth finger on the lateral forearm and compared with the
other side to uncover any differences that may indicate a pathological
condition. The ulnar pulse can be felt likewise on the medial side.
The brachial pulse is located on the medial upper arm, between the biceps and
the triceps.
On the lower extremities, the femoral popliteal, and posterior tibial artery, as
well as the dorsalis pedis arteries, are palpable. Examining the pulses in the
legs is particularly important for assessing peripheral artery disease.
Palpation should begin as proximal as possible, which means starting at the
femoral artery under the inguinal ligament.
If the femoral pulses are felt, the pedal pulses should be felt next.
These include the posterior tibial artery behind the medial malleolus, and
the dorsalis pedis, lateral to the extensor hallucis longus tendon.
If the pedal pulses are palpable, a stenosis of the leg arteries is unlikely
and palpating the more difficult to find popliteal pulse is generally not needed.
If the pedal pulses are missing, however, palpating the popliteal pulses with both
hands at the back of the knee may help in locating a stenosis.
If there is an arterial obstruction in the lower leg, the popliteal pulse is
still palpable, whereas an occlusion in the upper leg would result in an absent
pulse.
In addition to palpation, auscultation is an important part of examining the
peripheral arteries.
Locations for auscultation include: the common carotid artery in the carotid
triangle, the subclavian artery above or below the clavicula,
the brachial artery above the cubital fossa, the abdominal aorta in the upper
middle abdomen, the renal arteries lateral to this point, the iliac artery
in the lower abdomen, the femoral artery below the inguinal ligament, as well as
the popliteal artery behind the knee.
In healthy patients, sounds should not be audible on auscultation. Circulation
noises - known as brutes - arise only when blood flow is turbulent or accelerated
due to, for example, atherosclerotic changes, or an aneurysm.
When a brute is heard, its localization, intensity, frequency, and relation to
heartbeat, should be specifically evaluated.
Since the cause of a brute is not possible to determine through
auscultation alone, additional diagnostic steps should be taken for further
assessment.
Another important procedure for assessing the anastomosis between the
radial and ulnar arteries is the Allen Test which is described in another video.
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