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


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).


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

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  • 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.

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