All patients with risk factors and those with a clinical presentation suggestive of PAD should undergo a comprehensive vascular exam from head to toe. The routine vascular exam should start with blood pressure measurement, performed in both arms to assess for significant subclavian artery stenosis. A systolic blood pressure difference of > 15 to 20 mmHg between the two arms should suggest subclavian artery stenosis. The carotid and subclavian arteries should also be auscultated for the presence for bruits. The abdominal aorta should be palpated to assess for abdominal aortic aneurysm. The abdominal vascular exam should include auscultation for bruits, which are occasionally present in patients with renal artery stenosis. Rarely, a bruit may also be heard in patients with celiac and mesenteric artery stenosis.
The lower extremity vascular examination should be performed with the patient in a supine position. The assessment should include inspection of the skin for discoloration, pallor, hair loss, nail changes, calluses, ulceration, or infection. Examination of peripheral arteries should include palpation of the femoral, popliteal, dorsalis pedis, and posterior tibial arteries and auscultation of the iliac and femoral arteries for bruits. If the pedal pulses are not palpable, a handheld Doppler device may be used. Monophasic flow by Doppler is suggestive of significant PAD, whereas a triphasic or biphasic flow pattern is considered normal.