The most important sign of arterial insufficiency is a decreased pulse. In patients in whom chronic arterial insufficiency of the lower extremity is suspected, another test may be useful. The amount of pallor that develops after elevation and dependency of the ischemic extremity provides an approximate guide to the extent of decreased circulation. The patient is asked to lie on the back, and the examiner elevates the patient's legs at about 60° above the bed. The patient is asked to move the ankles to help drain the blood from the venous system, making the color changes more obvious. After about 60 seconds, the feet are inspected for pallor. Normally, no pallor is present (grade 0). Definite pallor in 60 seconds is grade 1;pallor in 30 to 60 seconds is grade 2;pallor in less than 30 seconds is grade 3;and pallor without elevation is grade 4. The patient is then asked to sit dangling the feet off the side of the bed, and the examiner assesses the time for color return. Normally it takes 10 to 15 seconds for color to return and 15 seconds for the superficial veins to fill. If it takes 15 to 25 seconds for color return, moderate occlusive disease is present; if it takes more than 40 seconds for color to return, severe ischemia is present. A dusky or cyanotic color may also develop. This test is useful only if the valves of the superficial veins are competent.
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