Results of external iliac artery reconstruction in avid cyclists

Short- and long-term outcome after endarterectomy with autologous patching in endurance athletes with iliac artery endofibrosis

OBJECTIVES

Endurance athletes such as cyclists may develop intermittent claudication due to iliac artery endofibrosis following long lasting extreme hemodynamic challenges. This study investigated short-term (<1.5 years) and long-term (>5 years) satisfaction and safety after a surgical endarterectomy and autologous patching.

METHODS

Data of endurance athletes who underwent an endarterectomy for flow limitation of the iliac artery (FLIA) due to endofibrosis between 1997 and 2015 in one centre were studied. Maximal cycling exercise tests, ankle-brachial index with flexed hips (ABI_Flexed), echo-Doppler examination (PSV, peak systolic velocity) and contrast enhanced magnetic resonance angiography were performed before and 6-18 months after surgery. Short-term and long-term satisfaction were evaluated using questionnaires. Potential patch dilatation was assessed using echo-Doppler.

RESULTS

Analysis of 68 patients (79 legs; 55.7% males, median age at the time of surgery 34 years, interquartile range 26-41 years) demonstrated that cycling workload at symptom onset improved from 226±97 to 333±101 (P<0.001) Watts. Peak workload increased from 326±111 to 352±93 Watts (P<0.001). ABI_Flexed increased from 0.34 (0.00-0.47) to 0.59 (0.51-0.69, P<0.001). PSV with extended and flexed hip decreased from 2.04 (1.52-2.56) to 1.25 (0.92-1.62, P<0.001) and 2.40 (1.81-2.81) to 1.15 (0.97-1.60, P<0.001) m∙sec^-1, respectively. Thirty-day major complication rate was 5.1% (hematoma requiring evacuation n_Legs=2, septic bleeding from deep infection n_Legs =1, iliac occlusion requiring thrombectomy n_Legs =1). In the short term, 91.2% patients reported symptom reduction with a 93.7% overall satisfaction rate. After a median of 11.1 years (7.8-17.6), the overall satisfaction was 91.7% whereas 94.5% reported persistent symptom reduction. Patch dilatation >20 mm was observed in two patients. Linear mixed model analysis revealed no alarming patch dilatation in the long term.

CONCLUSION

Endarterectomy with an autologous patch for intermittent claudication due to iliac artery endofibrosis in endurance athletes shows high rates of patient satisfaction and symptom reduction in both the short and long term. Risk of surgical complications or patch dilatation is mild. A surgical intervention for FLIA due to endofibrosis is safe and successful.

Anatomic factors contributing to external iliac artery endofibrosis in high performance athletes

INTRODUCTION

External iliac artery endofibrosis (EIAE) classically presents in cyclists with intimal thickening of the affected arteries. We investigated possible anatomical predisposing factors including psoas muscle hypertrophy, arterial tortuosity, inguinal ligament compression, and arterial kinking via case-control comparison of symptomatic and contralateral limbs.

METHODS

All patients with unilateral EIAE treated surgically at our institution were reviewed. Each patient's symptomatic side was compared with their contralateral side using paired t-tests. Psoas hypertrophy was quantified by transverse cross-sectional area (CSA) at L4, L5, and S1 vertebral levels, and inguinal ligament compression was measured as anterior-posterior distance between inguinal ligament and underlying bone. Tortuosity index for diseased segments and arterial kinking were measured on TeraRecon.

RESULTS

Of 33 patients operated on for EIAE from 2004-2021, 27 with available imaging presented with unilateral disease, more commonly left-sided (63%). Most (96%) had external iliac involvement and 26% had ≥2 segments affected: 19% common iliac artery, 15% common femoral artery. The symptomatic limb had greater mean L5 psoas CSA (1450 mm² vs. 1396 mm², mean difference 54 mm², P=0.039). There were no significant differences in L4 or S1 psoas hypertrophy, tortuosity, inguinal ligament compression, or arterial kinking. 63% underwent patch angioplasty and 85% underwent additional inguinal ligament release. 84% reported postoperative satisfaction, which was associated with greater difference in psoas hypertrophy at L4 (p=0.022).

CONCLUSIONS

Psoas muscle hypertrophy is most pronounced at L5 and is associated with symptomatic EIAE. Preferential hypertrophy of the affected side correlates with improved outcomes, suggesting psoas muscle hypertrophy as a marker of disease severity.

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.

External Iliac Artery Endofibrosis in a Female Cyclist: A Case Report

External iliac artery endofibrosis is a rare disease described mainly in male endurance athletes. It presents as claudication of the lower limb during near-maximum effort. The patients lack the usual risk factors for atherosclerosis, which makes diagnosis challenging. We present a case of external iliac artery endofibrosis in a female competitive cyclist. The initial surgical management was complicated by early recurrence due to intimal hyperplasia. After secondary drug-eluting balloon angioplasty, the patient was able to resume competition. As such, it is important to maintain a high index of suspicion when evaluating a patient presenting with claudication symptoms in this setting. Primary treatment is surgical, and in cases of early recurrence angioplasty may be indicated. Most patients can return to full activity after healing is complete.

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.

Conditions presenting with symptoms of peripheral arterial disease

Peripheral artery disease (PAD) is estimated to affect more than 20% of people older than 65 years. The vast majority of patients with symptoms suggestive of PAD have atherosclerosis often associated with conventional vascular risk factors such as smoking, diabetes, dyslipidemia, and inflammation. A minority of people presenting with symptoms suggesting PAD have an alternative etiology. These groups of disorders are often underdiagnosed, and if diagnosed correctly the diagnosis may be delayed. Understanding these pathologies well is important, as they can be very debilitating and optimal treatment may vary significantly. Inappropriate treatment of these disorders can lead to worsening morbidity and mortality. This article discusses the underlying causes of nonatherosclerotic PAD, including the diagnosis and treatment of these disorders.

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.