1. Right common carotid
2. Left common carotid
3. Left subclavian
4. Brachiocephalic (innominate)
5. Right axillary
6. Aortic arch
7. Ascending aorta
8. Left profunda brachii
9. Left brachial
10. Cubital anastomosis
11. Left ulnar
12. Left radial
13. Right deep palmer arch
14. Right superficial palmer arch
15. Descending thoracic aorta 16. Abdominal aorta
16. Abdominal aorta
17. Right common iliac
18. Left internal iliac
19. Right external iliac
20. Left common femoral
21. Left profunda femoris
22. Right superficial femoral
23. Geniculate anastomosis
24. Left popliteal
25. Left anterior tibial
26. Right peroneal
27. Left posterior tibial
28. Right dorsalis pedis
29. Right plantar arch
Arteries may bleed or block. The former is usually due to trauma, but may be from rupture of an aneurysm or from an arteriovenous malformation. Arteriosclerosis produces arterial stenosis and occlusion. In the coronary and cerebral vessels this gives rise to myocardial infarction and stroke respectively, and these effects are currently the commonest cause of death in the Western World. Reduction in blood flow to the lower limb gives rise to claudication (pain on exercise) and, when more severe, rest pain, nutritional changes to the skin and ultimately gangrene (figure 65).
Examination of the pulses is usually undertaken regionally, but in patients with arterial disease, a more systematic approach is required, as followed in this section. Figure 66 shows the main arteries in the body.
To feel a pulse effectively it is compressed on a firm adjacent structure, usually a bone (figure 67). The distal of three fingers is used to compress the vessel while the proximal two assess the rate, rhythm, volume and character of the pulse: rolling the vessel indicates a normal or thickened vessel wall. Commence by examining the radial pulses at the wrist, compressing the vessels on the lower end of each radius.
Radial and femoral pulses are compared for the radio-femoral delay of coarctation of the aorta (figure 68).
It is useful to compare the two sides of the body and also to compare the apical rate with an upper limb or cervical pulse, to look for missed beats, as for instance in atrial fibrillation (figure 69a,b).
The ulnar artery passes superficial to the lateral aspect of the flexor retinaculum and is prominent in some individuals (figure 70). The distal arteries may be occluded by emboli due to proximal disease, such as a cervical rib (figure 71).
If a subject first clenches their fist firmly, while you compress both the radial and ulnar arteries, when the fist is released return of the capillary circulation is slow. The relative contribution of these two vessels to the circulation of the hand can be assessed by the effect of individual compression (Allen’s test – figure 72a,b).
The brachial artery lies superficial at the level of the elbow joint, medial to the tendon of biceps, partly covered by the bicipital aponeurosis. To facilitate palpation, ask the subject to fully extend the elbow, to allow compression of the artery against the lower end of the humerus. It is at this site that the pulse is usually auscultated when measuring the blood pressure (figure 73a). You can also palpate the brachial artery against the midshaft of the humerus (figure 73b), in the groove between brachialis and biceps muscles. The axillary artery is palpated against the head of the humerus, by deep lateral palpation in the depths of the axilla (figure 73c). Palpate the subclavian artery by compression against the first rib. This is in the posterior triangle of the neck just behind the middle of the clavicle (figure 74)
The common carotid arteries can be palpated in the midcervical region, pressing backwards on the transverse processes of the cervical vertebrae (figure 75).
Unilateral or bilateral carotid compression is undertaken in this region (figure 76a,b). The common carotid bifurcation can be felt more distally, at the upper border of the thyroid cartilage; the external and internal branches are difficult to define independently.
Palpate the facial artery on the inferior margin of the mandible, just anterior to the masseter muscle (figure 77a). The border of the muscle can be identified by asking the subject to clench their teeth.
Palpate the superficial temporal artery at a preauricular level or its anterior division as it crosses the temple (figure 77b).
Soft bruits are commonly found over major arteries, even in normal individuals. However, stenotic disease often produces high pitched and prominent sounds. These signs, together with other symptoms and signs of stroke or lower leg ischemia, prompt more detailed investigation of the vascular tree.
Listen to the carotid arteries in the lower cervical region, over the carotid bifurcation and the orbit, the subclavian over the first rib, the axillary in the lateral axilla and the brachial in the arm and cubital fossa (figure 78a–f). The relation of carotid artery disease to stroke has led to the refinement of a number of measurement techniques to be use in this area (figure 79a–e).
Palpate the abdominal aorta above and below the umbilicus (figure 80a,b). It is easily felt in thin individuals and, when you first notice this, it can be mistaken for enlargement.
The aorta is difficult to feel in the obese, and when looking for aneurysms, press backwards with two hands, one on either side of the aorta, to obtain an estimate of its diameter (figure 81a,b). Abdominal ultrasound, or another imaging modality, is required to exclude or confirm the presence of a suspected aneurysm, and determine its size. If your hand can palpate the top of an abdominal aortic aneurysm, it is infrarenal (even when you cannot, it usually is). MRI provides good imaging and information of the surrounding structures (figure 82).
Listen to the aorta at the level of the umbilicus, and the iliac vessels from the aortic bifurcation (just to the left of the umbilicus, at the level of the L4 vertebral body) to the midinguinal point (midway between the anterior superior iliac spine and the symphysis pubis – figure 83a–d)).
Epigastric bruits are common in the young, but may represent aortic branch disease in the elderly (figure 84a). Bruits in either loin are an important diagnostic sign in suspected renal artery disease (figure 84b). The aorta and iliac vessels are common sites for arteriosclerotic disease (figure 85a,b).
Palpate the femoral arteries over the midinguinal point, compressing them backwards onto the head of the femur (figure 86). Compare the two sides for volume; they may differ in lower limb vascular disease, when bruits are also common (figure 87a–c).
1. Aortic bifurcation
2. Right common iliac artery
3. Left internal iliac artery
4. Left external iliac artery
5. Midinguinal point
6. Iliopsoas muscle
7. Right common femoral artery
8. Pectineus muscle
9. Sartorius muscle
10. Left profunda femoris artery
11. Left superficial femoral artery
12. Adductor longus muscle
The superficial position of the femoral arteries facilitates their ultrasound assessment, and their value for vascular access (figure 88a,b). Anatomically, the femoral artery extends from its formation at the inguinal ligament to where it becomes the popliteal, at the adductor hiatus. In clinical practice, the femoral is referred to as the common femoral, down to its profunda branch, and the superficial femoral artery beyond. This is in keeping with the way arterial disease often differs at these two sites.
Palpate the popliteal artery against the upper end of the tibia, with the knee slightly flexed and the muscles relaxed. Use the pulps of all eight fingers to compress the artery onto the tibia, between the heads of gastrocnemius (figure 89a). The popliteal artery is deeply situated in the popliteal fossa, but you can palpate it against the lower end of the femur, with the patient supine or prone (figure 89b,c). This is particularly useful if the distal popliteal artery is occluded.
Listen to the superficial femoral and popliteal arteries at the level of the adductor canal and over the popliteal fossa (figure 90a,b).
The anterior tibial artery crosses the ankle joint midway between the two malleoli, becoming the dorsalis pedis at this point. It then passes towards the first interdigital web. Palpate the latter over the heads of the metatarsals, just lateral to the extensor hallucis longus tendon (figure 91a–c).
The posterior tibial artery passes under the foot. You can palpate it behind the lower tibia or over the talus, midway between the medial malleolus and the medial prominence of the heel, before it passes into the sole (figure 92a,b).
The anterior perforating branch from the peroneal artery can be palpated just in front of the lateral malleolus. The vessel may be palpable in the normal individual or may become prominent with occlusion of other foot vessels (figure 93).
Foot pulses can be difficult to feel and you can be confused by feeling pulsation in your own fingers. If in doubt, palpate an easily palpable wrist or femoral pulse at the same time, or count out the beats of the palpated pulse, while another observer compares this with the pulse rate taken at another site.
In severe ischemia, the blood pressure at the ankle is markedly reduced and, as this approaches zero, the foot blanches and the veins empty, if you raise the foot. In extreme cases, a gutter replaces the line of the vein. When you subsequent lower the ischemic limb, venous refilling can take over a minute, compared to the normal few seconds, and this is followed by a distal reactive hyperemia.
In severe ischemia there may be trophic changes. Observe the lateral side of the foot and the heel for evidence of fissuring or infection, and examine between the toes for ulceration and gangrene. Diabetic patients are prone to foot ischemia, and these problems are accentuated by the associated neuropathy and infection.