How to Perform a PAVE Exam for Suspected PAD
I need to clarify that there is no standardized "PAVE exam" in the medical literature or clinical guidelines for peripheral artery disease assessment. The evidence provided discusses comprehensive PAD evaluation, but does not reference a "PAVE" examination protocol. I will instead provide the evidence-based approach to examining patients with suspected PAD, which may be what you're seeking.
Initial Clinical Assessment Components
The examination should include systematic pulse palpation and specific clinical findings that indicate PAD presence. 1
Pulse Examination Technique
Palpate all four pedal pulses bilaterally (dorsalis pedis and posterior tibial arteries in both feet), grading each as absent (0/3), reduced (1/3), normal (2/3), or bounding (3/3). 1, 2
When all four pedal pulses are present and palpable, the negative predictive value is 94.9%, making PAD highly unlikely and potentially eliminating the need for immediate ABI measurement in screening contexts. 2, 3
If one or more pedal pulses are absent, proceed immediately to ABI measurement, as this has 71.7% sensitivity and 72.3% specificity for PAD detection. 3
Palpate femoral pulses bilaterally and auscultate for femoral bruits, as their presence significantly increases PAD likelihood. 1, 2
Additional Physical Examination Findings
Look for these specific clinical signs that alert you to PAD presence: 1
- Cool lower limb temperature (poikilothermia) compared to the contralateral limb or proximal leg
- Pallor or dependent rubor of the foot
- Slow venous filling time (>15 seconds after leg elevation)
- Femoral bruits on auscultation
- Absent or diminished pulses at any level (femoral, popliteal, dorsalis pedis, posterior tibial)
Diagnostic Testing Algorithm
For Patients with Suspected PAD (Non-Acute)
Measure resting ABI as the cornerstone initial diagnostic test when clinical examination suggests PAD (absent pulses, symptoms, or risk factors). 1
ABI Interpretation and Next Steps: 1
- ABI ≤0.90: PAD confirmed; proceed to guideline-directed medical therapy and assess symptom severity
- ABI 0.91-1.30 with symptoms: Perform exercise treadmill ABI testing to unmask PAD
- ABI >1.40: Non-compressible vessels (common in diabetes); measure toe-brachial index (TBI) with waveforms instead
For Patients with Diabetes and Foot Ulcers
Always evaluate for PAD presence by measuring ankle or pedal Doppler arterial waveforms, ankle systolic pressure, and ABI, as up to 50% have concomitant PAD. 1
When ABI is unreliable (>1.40 or diabetes with calcification), obtain: 1
- Toe pressure/toe-brachial index (TBI) with waveforms
- Transcutaneous oxygen pressure (TcPO2)
- Skin perfusion pressure (SPP)
For Patients with Suspected Critical Limb-Threatening Ischemia (CLTI)
Use toe pressure/TBI with waveforms, TcPO2, and/or SPP in addition to ABI to establish CLTI diagnosis and assess wound healing potential. 1
High-Risk Patient Identification
Perform annual PAD screening in patients with: 1
- Age ≥70 years (any patient)
- Age 50-69 years with smoking history or diabetes
- Age <50 years with diabetes plus one additional atherosclerosis risk factor (smoking, dyslipidemia, hypertension, hyperhomocysteinemia)
- Leg symptoms with exertion or ischemic rest pain
- Known atherosclerotic disease (coronary, carotid, or renal artery disease)
Critical Pitfalls to Avoid
Never assume palpable pedal pulses exclude PAD in high-risk patients, particularly those with diabetes, as neuropathy may mask symptoms and calcification may produce falsely elevated ABIs. 1, 4
Do not rely on symptoms alone for PAD detection, as many patients are asymptomatic or have atypical leg symptoms rather than classic claudication. 1
Always measure ABI before applying compression therapy for venous disease, as approximately 16% of venous leg ulcer patients have unrecognized arterial disease, and compression with ABI <0.6 is contraindicated. 5
In patients with absent pulses in both feet, PAD is virtually certain (ankle indices <90%), and these patients require immediate vascular assessment. 6