Peripheral Arterial Disease assessment:
Do you hear what I hear?
This is an online teaching aid for clinicians involved in the assessment of peripheral arterial disease.
Real-life arterial sounds are only as good as the angle of the probe and should be considered alongside the full vascular assessment.
Full vascular assessment
A vascular assessment should be seen as a head to toe assessment. Start at the femoral and work your way down. It’s more logical.
Logical order of assessment
Vascular Nurse: “Intermittent Claudication (IC) is easy to assess its pain only on exercise, never at rest. Worse on an incline nine out of ten times, no symptoms on sitting, no symptoms in bed.”
Vascular Podiatrist: “It is poorly reported outside of the vascular world. There is a tendency to refer all leg pain to screen out vascular involvement. Vascular assessment requires a logical structure.”
The use of stratified assessment tools will support your assessment, for example the Edinburgh Claudication Questionnaire.
Asking about other related symptoms will inform diagnosis against your differential diagnosis e.g. lower back pain, hip symptoms, anything affecting reporting of the symptoms.
Vascular Nurse: “We receive referrals for suspected IC saying ‘pain during night, pain whilst sat’ and you think ‘oh dear, it’s not vascular!’”
PAD specific ones include heart attack, stroke, diabetes, cholesterol, blood pressure, smoking, diet, exercise, weight management.
Anti-platelet, statin, anti-hypertensive, diabetes medication.
Pulse palpation, can you feel the pulse points. The radial artery (in the wrist), common femoral artery (in the groin), the popliteal artery (behind the knee), the posterior tibial artery (medial ankle, behind malleolus) and the dorsalis pedis artery (top of the foot, between the 1st and 2nd metatarsals). Pulses are either palpable or they are not, and if not then further assessment should be arranged.
'An ankle brachial pressure index (ABPI) is a simple non-invasive method of identifying arterial insufficiency within a limb. It compares the ankle and brachial systolic blood pressures.
Question: “Do you ever listen to the quality of the sound from a Doppler assessment, or would you just put that down to the probe angle? i.e. a quiet sounding pulse for example”
Vascular Podiatrist: “I would use additional words, dull or strong monophasic in a report but it’s not a terminology I find anywhere that is standardised. It’s not used from a diagnostic point of view, it’s not overly supported in the literature. It’s used in the context of severity, I’m stating on that day what I heard.”
Vascular Nurse: “We just use three terms, triphasic, biphasic and monophasic.”
Vascular Sonographer: “We’d go with dampened or pulsatile but that’s because we can see the wave. We’d not just be looking at the sound, it’s the waves peak and distance.”
Vascular Podiatrist: “We get a lot of monophasic pulses where it’s fairly sharp and then we get the little domes and I want some words to differentiate between the two, because it does differentiate between the clinical decision sometimes, but it’s about the whole clinical picture.”