Red flag symptoms - Absent peripheral pulses

The possible red flags of patients presenting with absent peripheral pulses, including recognising risk factors of peripheral vascular disease, identify causes of claudication and when to refer.

Arterial ulcer is a symptom of PVD, also indicated by the poor condition of the patient's veins
Arterial ulcer is a symptom of PVD, also indicated by the poor condition of the patient's veins

The 'Ps' of PVD include:

  • Pallor
  • Perishing with cold
  • Pain
  • Pulselessness
  • Paraesthesia
  • Paralysis

Absent peripheral pulses may be indicative of peripheral vascular disease (PVD).

PVD may be caused by atherosclerosis, which can be complicated by an occluding thrombus or embolus. This may be life-threatening and may cause the loss of a limb.

It may be a chronic process and/or there may be acute ischaemia; this tends to occur more commonly in the lower limbs.

Possible causes of claudication

  • PVD
  • Baker's cyst
  • Chronic compartment syndrome
  • Nerve root compression
  • Spinal stenosis
  • Trauma

History

It is important to elicit a history of cardiac disease or known PVD. Moreover, a history of AF, stroke and renal disease should be sought.

Most emboli causing acute ischaemia are cardiac in origin. If there is a history of PVD, a collateral circulation may have had time to become established.

It is helpful to assess whether there are risk factors for PVD, such as smoking, diabetes, hyperlipidaemia, hypertension and coagulopathies. The drug history may be indicative of secondary prevention.

Establishing the location of intermittent claudication may be helpful. It is worth asking about exercise tolerance and if pain is relieved on resting. Rest pain may be alleviated by placing the limb in a dependent position. If this is present, PVD and reduced cardiac output may be leading to ischaemia. Buttock pain, erectile dysfunction and cold legs may be suggestive of aortoiliac obstruction (Leriche syndrome).

Examination

The cardiovascular system should be examined and an assessment made of the peripheral pulses, including the carotid, abdominal and femoral pulses. Auscultation for bruits should be performed.

Inspection of the skin may reveal an atrophic or livedo reticularis appearance. There may be evidence of ulceration or gangrene. Pressure areas may be affected by ulceration.

Capillary refill time and temperature of the extremities should be assessed. The Allen's test may be useful.

If there is concern about PVD, an ankle-brachial pressure index measurement is helpful. The ankle systolic pressure is divided by the brachial pressure in the supine position. The ratio is normally >1.

In the chronic setting, blood tests and an ECG may be helpful to allow for secondary prevention of PVD. Doppler ultrasound studies may be requested.

When to refer

Critical limb ischaemia refers to persistent ischaemic rest pain of more than two weeks' duration that may be associated with ulceration or gangrene of the toes/feet or with an ankle pressure less than or equal to 50mmhg or toe pressures less thank or equal to 30mmhg.

An urgent vascular opinion should be sought for acute or critical limb ischaemia. Younger patients with claudication may be referred early to exclude entrapment syndromes.

  • Dr Kochhar is a GP principal in Bexhill, East Sussex

Take a test on this article and claim your certificate on MIMS Learning

Resources

  • European Society of Cardiology.
  • Diagnosis and treatment of peripheral artery disease. Eur Heart J 2011; 32: 2851-906.
  • Peach G, Griffin M, Jones KG et al. Diagnosis and management of peripheral arterial disease. BMJ 2012; 345: e5208.

Have you registered with us yet?

Register now to enjoy more articles and free email bulletins

Register

Already registered?

Sign in

Follow Us:

Just published

First COVID-19 jabs to target care home residents and staff under new JCVI advice

First COVID-19 jabs to target care home residents and staff under new JCVI advice

Older adults living in care homes and staff working there will be first to receive...

GPs unable to veto virtual fitness to practise hearings during pandemic

GPs unable to veto virtual fitness to practise hearings during pandemic

GPs facing fitness to practise investigations during the COVID-19 pandemic will be...

Government rejects major NHSPS overhaul - but changes 'could ease GP service charge disputes'

Government rejects major NHSPS overhaul - but changes 'could ease GP service charge disputes'

A government review has rejected calls for a major overhaul of an NHS Property Services...

RCGP urges GPs to collaborate with pharmacies on flu jabs this year

RCGP urges GPs to collaborate with pharmacies on flu jabs this year

The RCGP and the Royal Pharmaceutical Society have called on GP practices and community...

GP appointments rising fast as COVID-19 cases 'near 10,000 a day'

GP appointments rising fast as COVID-19 cases 'near 10,000 a day'

GP appointments have risen rapidly in recent weeks as schools returned, according...

COVID-19 impact on medical schools risks 'serious damage' to future NHS workforce

COVID-19 impact on medical schools risks 'serious damage' to future NHS workforce

Medical training and the future NHS workforce could be seriously damaged by the financial...