External Iliac Endofibrosis in Endurance Athletes: A Novel Case in an Endurance Runner and a Review of the Literature

Long-term outcome of percutaneous endovascular stenting in external iliac artery endofibrosis

BACKGROUND

External iliac artery endofibrosis (EIAE) is a rare vascular disease which has been traditionally seen in avid cyclists. The conventional approach has been surgery, although no high-quality evidence suggests superiority of surgery over percutaneous endovascular intervention. There are limited data on the efficacy of stenting in EIAE.

METHODS

Over a 14-year period, we treated 10 patients (13 limbs) with EIAE with stents. These patients had declined surgery. The mean follow up was 8.4 ± 3.3 years. There were eight women. Five patients were competitive runners, three were cyclists, and two were triathletes. The mean age was 40.7 ± 2.9 years and body mass index was 19.46 ± 1.6. Intravascular ultrasound (IVUS) was used in eight limbs.

RESULTS

Procedural success was achieved in all. The recurrence of symptoms occurred in three patients at a mean of 9.3 ± 2.1 months postindex intervention. The other seven patients remained symptom free. IVUS revealed a pathognomonic finding which we termed 'perfect circle appearance'. It results from symmetric or asymmetric hypertrophy of one or more layers of the arterial wall leading to negative remodeling, which creates a distinct echo dense structure contrasting itself from the luminal blood's echoluscent appearance. It is identical to IVUS images of diffuse venous stenosis with important implications in the treatment technique.

CONCLUSIONS

We conclude that stenting in EIAE is safe and effective with a good long-term outcome. It can be an alternative to surgery, particularly in those patients who refuse a surgical approach. The IVUS image is pathognomonic and 'sine qua non' of EIAE.

Endofibrosis as a Causative Agent of the Peripheral Artery Disease: A Report of Two Cases for Professional Cyclists

Endofibrosis is a rare disease that predominantly affects athletes and is caused by a gradual occlusion of the (usually iliac) artery due to a thickening of the intima. From our experience, we report in this article two cases with the entity of endofibrosis in females around 30 years old. The first case presented with acute limb ischemia, and the second one was with pain in the leg during exercise. In addition, both cases are professional cyclists. They were eventually diagnosed with endofibrosis and underwent surgical procedures. They are now pursuing their professional career successfully. Last but not least, endofibrosis might be classified as an occupational disease, particularly, in the case of professional athletes or cyclists.

Covered Stents vs. Angioplasty for Common Iliac Artery In Stent Restenosis: A Retrospective Comparison

OBJECTIVE

The optimal endovascular treatment for common iliac artery in stent re-stenosis has yet to be assessed. Treatment options include, among others, angioplasty alone and repeated stenting with covered stents.

METHODS

This study retrospectively compared patency and target lesion revascularisation of these treatments. All patients who underwent endovascular treatment of common iliac artery in stent re-stenosis between 2007 and 2017 were included retrospectively. The primary end point was freedom from re-stenosis. Secondary endpoints were target lesion revascularisation rate (TLR) and freedom from occlusion during follow up.

RESULTS

Seventy-four interventions were included, consisting of 37 angioplasties and 37 covered stent placements in 57 patients. Freedom from re-stenosis at four years was 72.6% (95% confidence interval [CI] 51.8% - 88.7%) in the covered stent group vs. 43.5% (95% CI 25.9% - 59.8%) in the percutaneous transluminal angioplasty (PTA) group (p = .003). The target lesion revascularisation (TLR) rate was 16.4% (95% CI 7.1% - 35.6%) and 43.6% (95% CI 28.0% - 63.2%) respectively (p = .020). There was no difference in freedom from occlusion; this was 90.8% (95% CI 73.9% - 97.0%) in the covered stent group and 79.1% (95% CI 58.4% - 90.3%) in the PTA group (p = .49). The difference in freedom from re-stenosis and TLR remained significant after sensitivity and multivariable analyses.

CONCLUSION

Covered stents offer better outcomes for common iliac artery in stent re-stenosis than angioplasty alone.

Hip Position Acutely Affects Oxygenation and Perfusion of Kidney Grafts as Measured by Functional Magnetic Resonance Imaging Methods-The Bent Knee Study

Background: Kidney perfusion and oxygenation are two important determinants of kidney graft function. In kidney transplantation, repeated graft hypoperfusion may occur during hip flexion, for example in the sitting position, due to the progressive development of fibrotic tissue around iliac arteries. The aim of this study was to assess the changes in oxygenation and perfusion of kidney grafts during hip flexion and extension using a new functional magnetic resonance imaging (fMRI) protocol. Methods: Nineteen kidney graft recipients prospectively underwent MRI on a 3T scanner including diffusion-weighted, blood oxygenation level dependent (BOLD), and arterial spin labeling sequences in hip positions 0° and >90° before and after intravenous administration of 20 mg furosemide. Results: Unexpectedly, graft perfusion values were significantly higher in flexed compared to neutral hip position. Main diffusion-derived parameters were not affected by hip position. BOLD-derived cortico-medullary R2^* ratio was significantly modified during hip flexion suggesting an intrarenal redistribution of the oxygenation in favor of the medulla and to the detriment of the cortex. Furthermore, the increase in medullary oxygenation induced by furosemide was significantly blunted during hip flexion (p < 0.001). Conclusion: Hip flexion has an acute impact on perfusion and tissue oxygenation in kidney grafts. Whether these position-dependent changes affect the long-term function and outcome of kidney transplants needs further investigation.

Exercise induced leg pain due to endofibrosis of external iliac artery

Due to monotonous movement patterns, muscular hypertrophy, and increased cardiac output peripheral vasculature of athletes are subject to extreme stresses during athletic performance. Individuals suffering from exercise induced non-traumatic lower leg pain may display underlying vascular pathology such as external iliac artery endofibrosis. Therefore, it is essential in the course of to discriminate vascular from non-vascular findings and prime the correct diagnostic path within the course of clinical examination. In this regard, interdisciplinary thinking and profound knowledge in exercise-associated pathologies of the musculoskeletal, nervous and vascular system is indispensable. Consequently, provocation testing displays an indispensable diagnostic tool and has to be continued until symptoms occur, or complete exhaustion is attained. Finally, selective assessment of conservative and surgical treatment options, as well as its ethical evaluation, are of major importance in order to protect, preserve and promote the health and physical integrity of our patients who are keen to perform.

Functional magnetic resonance angiography in the diagnosis of iliac artery endofibrosis in an endurance runner

A 45-year-old woman was presented with a 2-year history of left lower limb claudication symptoms occurring only during long-distance running. Multimodal imaging with exercise duplex ultrasonography and magnetic resonance angiogram confirmed the presence of flow-limiting stenoses in the left external iliac artery consistent with a diagnosis of left external iliac artery endofibrosis. She successfully underwent a left external iliac endarterectomy with vein patch repair and returned to full physical activity soon after. A year following full recovery from her original operation, she presented with similar symptoms on the right side and was managed in a similar manner. This report illustrates an unusual case of bilateral iliac artery endofibrosis occurring in an older endurance runner. We also present a novel diagnostic modality of pre-exercise and postexercise magnetic resonance angiography for iliac endofibrosis.

Bilateral external iliac artery thrombosis due to endofibrosis in a 33-year-old female triathlete

External iliac artery endofibrosis is a rare disease predominantly affecting young, elite male athletes. This case involves a 33-year-old female triathlete who presented initially with lower extremity claudication during training. After completing a triathlon 1 year later, the patient experienced acute-onset pain in both legs. Computed tomography angiography showed abrupt occlusion of the bilateral proximal external iliac arteries. The patient underwent a right and left external iliac artery reconstruction using the ipsilateral great saphenous vein and reported significant improvement of claudication symptoms. The case highlights a rare complication of acute bilateral arterial thrombosis.

Protease-activated receptors are potential regulators in the development of arterial endofibrosis in high-performance athletes

OBJECTIVE

High-performance athletes can develop symptomatic arterial flow restriction during exercise caused by endofibrosis. The pathogenesis is poorly understood; however, coagulation enzymes, such as tissue factor (TF) and coagulation factor Xa, might contribute to the fibrotic process, which is mainly regulated through activation of protease-activated receptors (PARs). Therefore, the aim of this explorative study was to evaluate the presence of coagulation factors and PARs in endofibrotic tissue, which might be indicative of their potential role in the natural development of endofibrosis.

METHODS

External iliac arterial specimens with endofibrosis (n = 19) were collected during surgical interventions. As control, arterial segments of the external iliac artery (n = 20) were collected post mortem from individuals with no medical history of cardiovascular disease who donated their body to medical science. Arteries were paraffinized and cut in tissue sections for immunohistochemical analysis. Positive staining within lesions was determined with ImageJ software (National Institutes of Health, Bethesda, Md).

RESULTS

Endofibrotic segments contained a neointima, causing intraluminal stenosis, which was highly positive for collagen (+150%; P < .01) and elastin (+148%; P < .01) in comparison with controls. Intriguingly, endofibrosis was not limited to the intima because collagen (+213%) and elastin (+215%) were also significantly elevated in the media layer of endofibrotic segments. These findings were accompanied by significantly increased α-smooth muscle actin-positive cells, morphologically compatible with the presence of myofibroblasts. In addition, PAR1 and PAR4 and the membrane receptor TF were increased as well as coagulation factor X.

CONCLUSIONS

We showed that myofibroblasts and the accompanying collagen and elastin synthesis might be key factors in the development of endofibrosis. The special association with increased presence of PARs, factor X, and TF suggests that protease-mediated cell signaling could be a contributing component in the mechanisms leading to endofibrosis.

MRI to investigate iliac artery wall thickness in triathletes

OBJECTIVES

Endofibrosis was first described in endurance athletes. This rare disease is characterized by intimal hyperplasia of iliac arteries. Due to non-specific symptoms diagnosing could be very challenging and delayed. This represents a serious problem not only for affected athletes but also for consulting physicians. The aim of this study was to analyze intimal thickness of iliac arteries using non-contrast magnetic resonance imaging (MRI) in competitive triathletes suffering from exercise induced leg pain consistent with symptoms caused by endofibrosis.

METHODS

18 highly trained triathletes (16 triathletes, 12 male) with a mean age of 45.4 ± 10.2 years were investigated by non-contrast MRI. We divided subjects into two groups: 10 complaint about exercise- induced leg pain and 7 were free of any symptoms. In all 10 symptomatic athletes consulting physicians excluded musculoskeletal or neurological disorders before and we suspected endofibrosis. One patient was excluded from statistical analysis due to a known recurrent external iliac artery (EIA) occlusion after surgical repair 6 month ago.

RESULTS

Mean wall thickness (T) of all 17 subjects was 1.34 ± 0.11mm for the common iliac artery (CIA) and 1.74 ± 0.18mm for the EIA. We found no significant differences by comparing T of symptomatic (s) and asymptomatic (a) legs. There were no significant differences in mean ratio of patent artery to whole artery between the symptomatic and asymptomatic legs for the CIA (0.81 vs 0.82, p = 0.87) and for the EIA (0.71 vs 0.72, p = 0.78). MRI shows a thickening of the left EIA (4.41mm) in the patient who suffered from recurrent occlusion of the left EIA and after surgical repair and histological examination confirmed an endofibrotic lesion.

CONCLUSION

Non-contrast MRI seems to be an appropriate diagnostic tool to exclude endofibrosis in triathletes, but it cannot be recommended as initial screening modality for athletes suffering from exercise-induced leg pain.

External Iliac Artery Vasospasm in an Elite Female Runner

A 33-year-old elite female runner presented to a tertiary care sports medicine clinic with a 2-year history of progressive anterior thigh and circumferential leg pain with associated foot paresthesias brought on by high-intensity running. She had both external iliac artery vasospasm and chronic exertional compartment syndrome. External iliac artery vasospasm is a rare cause of exertional leg pain, particularly in the running population. This case highlights the unique features of this condition, addresses the multidisciplinary approach that led to the accurate diagnoses, and demonstrates that more than 1 etiology for exertional leg pain can coexist in an athlete.

Arterial endofibrosis in professional cyclists

External Iliac Artery Endofibrosis (EIAE) is an uncommon disease usually affecting young, otherwise healthy, patients. It usually involves cyclists but cases have been reported in other groups of endurance athletes. The external iliac artery is the most affected anatomical site but other locations are described too. The precise pathophysiology and long-term evolution of the disease still remain unknown. The diagnosis may be challenging and delayed as the patients usually present symptoms only in extreme conditions and physical and instrumental examinations may be normal at rest. We present two cases of young professional cyclists who suffered of exercise-induced leg pain which led them to reduce running. Both patients were firstly treated with balloon angioplasty that rapidly failed to improve their symptoms. The successive open surgery with endofibrosectomy and autologous saphenous vein closure patch completely resolved physical limitations. EIAE is a rare disease that can induce arterial stenosis, thrombosis, dissection and secondary atheroma. After-exercise ankle-brachial index represents a useful diagnostic criterion. Careful observation of angio-CT may strengthen the suspect. Knowledge of the these features allows a better pre-operative assessment and an early effective treatment. Surgical revascularization remains the gold standard approach.

External iliac artery endofibrosis in an amateur runner: hemodynamic, angiographic, histopathological evaluation and percutaneous revascularization

We describe a case of external iliac artery endofibrosis in an amateur competitive runner. The diagnosis was made by a combination of hemodynamic, angiographic and histopathological assessment and percutaneous revascularization was performed using a balloon expandable stent.

Bilateral Common Iliac Artery Endofibrosis in a Recreational Cyclist: Case Report and Review of the Literature

External iliac artery endofibrosis is a rare medical condition typically encountered in young endurance athletes, mainly cyclists. Iliac endofibrosis usually develops in the external iliac artery and is rarely seen in the common iliac or in common femoral arteries. We describe a unique case of a patient who was not a professional or high-endurance cyclist. The lesions in our case appeared to be bilateral in the common iliac arteries and were not limited to the external iliac artery as most commonly described. We present an overview of the literature regarding this medical condition.

Intravascular ultrasound imaging as a novel tool for the diagnosis of endofibrosis

Given the rise of high-intensity sport athletes and the paucity of literature on endofibrosis, we describe a novel adjunctive imaging technique to aid in diagnosis. A 41-year-old female triathlete presented with exercise-limiting claudication. Results of lower extremity magnetic resonance angiography, provocative Doppler, angiogram, and digital subtraction angiography with papaverine were nondiagnostic. Intravascular ultrasound imaging was able to delineate an abnormal segment of the proximal external iliac artery with intimal hypertrophy. We report intravascular ultrasound imaging as a superior imaging modality to definitively diagnose endofibrosis and assist proper planning and operative treatment of patients with endofibrosis.

Iliac artery endofibrosis in a middle-aged female long-distance runner

Exercise-induced iliac artery endofibrosis is a recently described abnormality of the external iliac artery that typically affects younger, healthy endurance athletes. Characteristic of the initially termed cyclist's iliac syndrome is lower limb pain during exercise with rapid recovery after exercise. This clinically complicated case describes an older female long-distance runner in whom an incorrect diagnosis of fibromuscular dysplasia was originally made when she presented with claudication and thrombosis of the right external iliac artery. A thrombectomy and bilateral balloon angioplasty were performed; however, her symptoms persisted. Four months later, she unexpectedly complained of dual calf claudication, a diagnosis of exercise-induced iliac artery endofibrosis was made, and a bilateral prosthetic graft bypass procedure was performed, which resulted in a good outcome.

An unusual case of leg pain in a competitive cyclist: a case report and review of the literature

Cycling has become a popular recreational and competitive sport. The number of people participating in the sport is gradually increasing. Despite being a noncontact, low-impact sport, as many as 85% of athletes engaged in the sport will suffer from an overuse injury, with the lower limbs comprising the majority of these injuries. Up to 20% of all lower extremity overuse injuries in competitive cyclists are of a vascular source. A 39-year-old competitive cyclist had a 5-year history of thigh pain during cycling, preventing him from competing. The patient was eventually diagnosed with external iliac artery endofibrosis. After conservative treatment failed, the patient underwent corrective vascular surgery with complete resolution of his symptoms and return to competitive cycling by 1 year. Since its first description in 1985, there have been more than 60 articles addressing external iliac artery endofibrosis pathology.

Vascular disorder in a competitive cyclist: a case report

The purpose of this case report was to alert the physical therapist (PT) to the possibility of vascular disorders in endurance athletes with apparent musculoskeletal symptoms. A 33-year-old female injured her knee in a fall and described a history of progressive unilateral lower extremity (LE) pain and weakness, especially with running and cycling. She received LE stretching and strengthening but her symptoms persisted, so she stopped all activity. When she became symptomatic with minimal exertion, she went to a neurologist, but electromyographic (EMG)/nerve conduction velocity (NCV) studies were normal. Eventually, she was referred for vascular studies, which confirmed a diagnosis of external iliac artery endofibrosis. The patient underwent a right common iliac to common femoral artery bypass graft approximately 3 years after onset of initial symptoms. She ran a 5K race 3 weeks after surgery and returned to cycling after 4 weeks. Endofibrosis of the external iliac artery is an uncommon disorder but is most frequently diagnosed in high-performance athletes, especially cyclists. Physical therapists who practice in orthopedic settings should be aware of vascular conditions that mimic musculoskeletal disorders in endurance athletes. Vascular consult or referral may be necessary if PT interventions are ineffective in treating athletes with exercise-induced LE pain and weakness.

Lower limb vascular dysfunction in cyclists

Sports-related vascular insufficiency affecting the lower limbs is uncommon, and early signs and symptoms can be confused with musculoskeletal injuries. This is also the case among professional cyclists, who are always at the threshold between endurance and excess training. The aim of this review was to analyze the occurrence of vascular disorders in the lower limbs of cyclists and to discuss possible etiologies. Eighty-five texts, including papers and books, published from 1950 to 2012, were used. According to the literature reviewed, some cyclists receive a late diagnosis of vascular dysfunction due to a lack of familiarity of the medical team with this type of dysfunction. Data revealed that a reduced blood flow in the external iliac artery, especially on the left, is much more common than in the femoral and popliteal arteries, and that vascular impairment is responsible for the occurrence of early fatigue and reduced performance in cycling.

DISCOVER: Dutch Iliac Stent trial: COVERed balloon-expandable versus uncovered balloon-expandable stents in the common iliac artery: study protocol for a randomized controlled trial

BACKGROUND

Iliac artery atherosclerotic disease may cause intermittent claudication and critical limb ischemia. It can lead to serious complications such as infection, amputation and even death. Revascularization relieves symptoms and prevents these complications. Historically, open surgical repair, in the form of endarterectomy or bypass, was used. Over the last decade, endovascular repair has become the first choice of treatment for iliac arterial occlusive disease. No definitive consensus has emerged about the best endovascular strategy and which type of stent, if any, to use. However, in more advanced disease, that is, long or multiple stenoses or occlusions, literature is most supportive of primary stenting with a balloon-expandable stent in the common iliac artery (Jongkind V et al., J Vasc Surg 52:1376-1383,2010). Recently, a PTFE-covered balloon-expandable stent (Advanta V12, Atrium Medical Inc., Hudson, NH, USA) has been introduced for the iliac artery. Covering stents with PTFE has been shown to lead to less neo-intimal hyperplasia and this might lower restenosis rates (Dolmatch B et al. J Vasc Interv Radiol 18:527-534,2007, Marin ML et al. J Vasc Interv Radiol 7:651-656,1996, Virmani R et al. J Vasc Interv Radiol 10:445-456,1999). However, only one RCT, of mediocre quality has been published on this stent in the common iliac artery (Mwipatayi BP et al. J Vasc Surg 54:1561-1570,2011, Bekken JA et al. J Vasc Surg 55:1545-1546,2012). Our hypothesis is that covered balloon-expandable stents lead to better results when compared to uncovered balloon-expandable stents.

METHODS/DESIGN

This is a prospective, randomized, controlled, double-blind, multi-center trial. The study population consists of human volunteers aged over 18 years, with symptomatic advanced atherosclerotic disease of the common iliac artery, defined as stenoses longer than 3 cm and occlusions. A total of 174 patients will be included. The control group will undergo endovascular dilatation or revascularization of the common iliac artery, followed by placement of one or more uncovered balloon-expandable stents. The study group will undergo the same treatment, however one or more PTFE-covered balloon-expandable stents will be placed. When necessary, the aorta, external iliac artery, common femoral artery, superficial femoral artery and deep femoral artery will be treated, using the standard treatment. The primary endpoint is absence of binary restenosis rate. Secondary endpoints are reocclusion rate, target-lesion revascularization rate, clinical success, procedural success, hemodynamic success, major amputation rate, complication rate and mortality rate. Main study parameters are age, gender, relevant co-morbidity, and several patient, disease and procedure-related parameters.

TRIAL REGISTRATION

Dutch Trial Register, NTR3381.

Cycling related common femoral artery disease: an unusual case in an otherwise healthy male

A cyclist reported gradual onset, bilateral leg claudication without any atherosclerotic risk factors and with a normal vascular examination. Duplex ultrasound and magnetic resonance angiography revealed bilateral focal stenoses due to coralline plaques of the common femoral arteries (CFAs) but normal proximal and distal vasculature. A surgical endarterectomy with vein patch angioplasty resolved all symptoms. Cyclist's iliac syndrome (whereby mechanical and anatomical factors in competitive cyclists and runners lead to arterial kinking and subsequent intimal hyperplasia, endofibrosis and, ultimately, stenoses of the external iliac arteries) is well documented. This is the first report to our knowledge of a similar process isolated to the CFA.

Skiing and intermittant claudication: an aberrant presentation

Lower extremity peripheral arterial disease frequently presents with intermittent claudication, typically manifest in lower extremity pain or cramping associated with exercise, generally walking. Occasionally early onset of disease can be associated with running. This report describes the unusual presentation of leg pain associated with skiing and relieved by cessation of skiing immediately caused by focal iliac artery stenosis.

Vascular disorders in athletes

Athletes rarely present with symptoms or clinical findings suggestive of vascular disease. However, vascular etiologies should be considered when an athlete complains of persistent symptoms which are refractory to conservative therapies commonly used for presumed musculoskeletal injuries. A comprehensive history should be performed, with special consideration to the postures the athlete assumes repeatedly during their chosen sport. Musculoskeletal anatomy surrounding the vascular bed of interest should be thoroughly reviewed. Physical examination should include provocative maneuvers specific to the suspected vascular disorder. The proper use of noninvasive diagnostic studies, including duplex ultrasonography, computerized tomography (CT), and magnetic resonance imaging (MRI), along with catheter-based angiography, when indicated, can ensure prompt diagnosis. Appropriate, multifaceted treatment of an athlete affected by a vascular disorder can facilitate an expeditious return to previous levels of activity.

THE CONUNDRUM OF CLAUDICATION

Stable claudication has traditionally been treated conservatively by many clinicians as operative therapies involve considerable risk for a condition that is often slowly progressive and non-fatal. The relative safety of less invasive endovascular techniques brings potential survival benefits from the increased exercise tolerance that result. We aimed to revisit and clarify the aetiologies of intermittent claudication in a review of the rarer causes that can mimic atherosclerotic occlusive disease. An extensive search of Medline, Embase and the Cochrane databases was carried out to compile published work addressing the aetiology of claudication and specific non-atherosclerotic causes. The reference lists of these manuscripts were also searched for relevant articles. There are several vasculogenic and neurogenic causes for intermittent claudication, many of which are unrelated to atherosclerosis. Recognition of these rarer syndromes is essential when planning endovascular or operative management strategies. Consideration of non-atherosclerotic differential diagnoses is recommended when assessing the patient with intermittent claudication. This is particularly critical in the young patient whose pattern of symptoms and risk factors may not fit precisely with atherosclerosis.

Endofibrosis of Iliac Arteries in High-Performance Athletes: Diagnostic Approach and Minimally Invasive Endovascular Treatment

The aim of this article is to report our experience in the diagnosis of two cases of iliac artery endofibrosis or arteriopathy, a rare entity occurring in high-performance athletes, presenting with intermittent claudication (right-sided in both) after maximal exercise. External iliac artery endofibrosis or arteriopathy is a likely diagnosis in competitive athletes free of cardiovascular risk factors who present with leg claudication. Arteriography and a papaverine-assisted mean pressure gradient across the iliac arteries of more than 10 mmHg is a useful diagnostic approach. Moreover, balloon angioplasty of the iliac artery in that patient, in whom a pressure gradient was detected, resulted in symptomatic relief for 2 months followed by mild symptom recurrence. Thus, although balloon angioplasty is feasible and safe, it might not be adequate to treat this entity and, thus, its value remains undefined.

Comparison Between Duplex Scanning and Angiographic Findings in the Evaluation of Functional Iliac Obstruction in Top Endurance Athletes

OBJECTIVE

Review of a 10 year-experience, to evaluate the efficacy of pre-operative investigations in the detection of external iliac artery (EIA) endofibrosis in top endurance athletes.

DESIGN

Retrospective study.

MATERIALS

From September 1995 to March 2004, 13 highly-trained athletes (all men, mean age 32.3 years) underwent surgery for disease involving 14 lower limbs (11 left, one right, one bilateral).

METHODS

We compared ultrasound scan (US) and digital subtraction angiography (DSA) data, at rest and at hip flexion with intra-operative findings for all 14 lower limbs. We analyzed the presence of stenosis in the external and common iliac arteries, the presence of psoas muscle arteries and the presence of excessive EIA length.

RESULTS

In the affected limbs, before treatment, the mean ankle brachial index (ABI) at rest was 0.98 compared with 0.56 after exercise, p=0.0001. The sensitivities of the US vs DSA examination in the detection of external and common iliac artery stenosis were, respectively, 84.6 and 53.8% vs 53.8 and 12.5%. The muscle psoas artery was detected by DSA with a sensitivity of 57.1 and 100% specificity. For the detection of excessive EIA length, the sensitivity of US was 85.7% with 57.1% specificity.

CONCLUSIONS

A fall of ABI after exercise proves the presence of a significant stenosis in symptomatic athletes. Color coded duplex ultrasonography is recommended for non-invasive imaging of suspected endofibrotic stenosis in young athletes, since it detects reliably both stenosis and elongation of iliacal arteries.