Peripheral Vascular Assessment Toolkit

Quick reference guide for pulse grading, edema assessment, and the Ankle-Brachial Index (ABI).

Key Documentation Note

Document peripheral edema in a way which facilitates future comparison. Note degree and level (e.g., 2+ pitting edema, approximately to mid-shin bilaterally). Limb girth can also be measured and recorded, particularly when asymmetric.

→ Review Peripheral Pulse Palpation → Edema Assessment Guidelines

Peripheral Pulse Grading

0:
Absent
1+:
Faint, but detectable
2+:
Slightly diminished
3+:
Normal pulse
4+:
Bounding

Peripheral Edema Grading (Pitting)

0:
No pitting edema
1+ (Mild):
2mm depression that disappears quickly
2+ (Moderate):
4mm depression that disappears in 10-15 seconds
3+ (Mod. Severe):
6mm depression which may last for more than 1 minute
4+ (Severe):
8mm depression which lasts more than 2 minutes

Ankle-Brachial Index (ABI) Screening

Screening Rationale for PAD

ABI is a fast and sensitive means to screen for Peripheral Arterial Disease (PAD). If a patient describes a symptom pattern consistent with vascular claudication (e.g., provoked by activity rather than position; relieved by rest) and/or presents with unexplained sensory, strength, or integumentary changes, and is at risk for PAD, screening is warranted.

Procedure & Best Practice

  1. Allow the patient to rest in a supine position prior to checking.
  2. Check Systolic BP (SBP) at the brachial artery (both arms, if possible). Check both arms as asymmetry can help screen for subclavian stenosis, with a delta of 15 mmHg or greater considered significant.
  3. Check SBP at the posterior tibial (PT) and dorsalis pedis (DP) arteries using a Doppler. Ensure appropriately sized cuffs are used.
  4. Calculation: Divide the higher SBP at the ankle (max of PT or DP) by the higher SBP at the arm (max of both brachials) to obtain the ABI value.
    ABI = (Highest Ankle SBP) / (Highest Brachial SBP)
  5. Situationally, ABI may be assessed at rest and again following physical activity.

Interpretation

Normal Range: 1.0 to 1.4
PAD Concern: ABI values < 0.9 (Often a threshold for vascular referral)
Vascular Calcification: ABI values > 1.4 (May indicate non-compressible arteries; threshold for vascular referral)

Calculation Example

Example: Patient's SBP at Right PT is 162 mmHg, Right DP is 158 mmHg. SBP at Right brachial is 125 mmHg and Left brachial is 118 mmHg.

  • Highest Ankle SBP: Max (162, 158) = 162 mmHg
  • Highest Brachial SBP: Max (125, 118) = 125 mmHg
ABI = 162 / 125 = 1.296

Interpretation: An ABI of 1.296 is at the higher end of the normal range. This is useful for future comparison or prompt communication to the care team if the patient is symptomatic.