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

Conservative Management and Postoperative Return to Sport in Endurance Athletes with Flow Limitations in the Iliac Arteries: A Scoping Review

BACKGROUND

Flow limitations in the iliac arteries (FLIA) is a sport-related vascular condition increasingly recognised as an occupational risk for professional cyclists and other endurance athletes. Surgical reconstruction is the definitive treatment for athletes wishing to continue competition. However, less information has been published regarding conservative management options and return-to-sport (RTS) guidelines.

OBJECTIVE

Our aim was to review the existing literature on conservative treatment of FLIA, identify knowledge gaps and propose an RTS framework for athletes returning to competition.

METHODS

A comprehensive literature review was performed using the Ovid-MEDLINE, PubMed, Embase and PEDro databases for publications relevant to conservative management of FLIA. A scoping review was conducted following PRISMA-ScR guidelines. Original, peer-reviewed publications in English describing conservative or postoperative management for athletes with FLIA were included. Additional grey literature and clinical expertise were consulted to inform RTS guidelines.

RESULTS

Overall, 62 studies were included in this review. In total, 11 categories of conservative modalities were extracted and presented qualitatively in terms of the information source (discussion or results statements) and perspective of the authors (positive, negative or mixed). We have proposed RTS guidelines covering pre-operative preparation and postoperative rehabilitation based on the available literature, clinical experience, and drawing from other areas of sports medicine research.

CONCLUSION

There is insufficient literature evaluating the effectiveness of conservative management options for FLIA to establish best practices. Considering the importance of RTS for competitive athletes, we proposed practical guidelines to help with clinician and patient decision making. Future consensus should be sought for RTS best practices.

[Iliac endofibrosis in high-performance sports: an interdisciplinary diagnostic challenge]

OBJECTIVES

Iliac endofibrosis (IE) is a rare arterial disease in endurance athletes, especially cyclists and triathletes. The diagnosis is considered challenging and the latency from the onset of initial symptoms to diagnosis is often several years. Diagnostic options include determination of the ankle brachial index (ABI) after maximal exercise as a non-invasive procedure, as well as duplex sonography, CT or MRI angiography, and invasive angiography. The aim of this paper is to analyse in more detail this time lag to correct diagnosis from the first description in 1985 to the year 2021, as well as to identify the most important diagnostic tools for practice.

MATERIALS AND METHODS

Literature research according to PRISMA criteria in PubMed, Web of Science, Cochrane databases, supplemented by a search in Google Scholar up to 10/18/2021.

RESULTS

We identified a total of 133 publications that dealt thematically with IE in endurance athletes. In 42 publications (40 case reports and 2 clinical trials), the diagnosis was confirmed intraoperatively, and in 32 (32/42; 74.4%), statements were made about the duration from the onset of the first symptoms to the final diagnosis (mean 45, median 36 months). This latency was constant over the entire observation period from 1985 to 2021, with no trend toward shortening. Twenty-four papers (24/42; 56%) reported detailed results of ABI determination as well as further diagnostic testing. In all cases, the ABI value decreased to less than 0.66 (in 5 case reports, this decrease was measured at rest; in 19 case reports, it occurred after stress), whereas further diagnostic testing by duplex sonography, DSA, MRA, or CTA revealed no abnormal findings in 3 cases (3/24; 12.5%) and showed no more than minor stenosis in 14 cases (14/24; 58.3%).

CONCLUSIONS

A drop in ABI after exercise is the most reliable method to diagnose iliac endofibrosis. This non-invasive and easy-to-perform examination should be integrated into the performance diagnostics of highly ambitious endurance athletes at risk. This may ideally prevent irreversible vessel wall damage by early diagnosis as well as a reduction of the presumed high number of undetected cases.

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.

Intensive Long Distance Running as a Possible Cause of Multiple Splanchnic Arterial Aneurysms: A Case Report

This is a case report that suggests the possible association between multiple splanchnic arterial aneurysms and long-distance running. The clinical features of one patient admitted at Chungbuk National University Hospital for treatment of multiple splanchnic arterial aneurysms were reviewed. A 54-year-old man had a recurrent, intermittent and epigastric pain for 2 months. There was no abnormality in gastroscopy and colonoscopy. An abdominal computed tomography angiography documented calcified superior mesenteric artery (SMA) and splenic artery aneurysms. The patient had a history of recreational long-distance running for over 10 years. His average running time per week was more than 10 hours. There was no evidence of systemic arteritis, connective tissue disorder or infectious process that may have caused the aneurysms. He did not take any drugs. The SMA aneurysm was opened, and the aneurysmal segment of SMA was replaced with a vein graft. The splenic aneurysm was observed. The patient recovered without any sequelae.

A Case of Endofibrosis Presenting with Embolic Symptoms in a 43-Year-Old Cyclist

BACKGROUND

Endofibrosis is a rare clinical entity that usually manifests as claudication in cyclists and other endurance athletes. We report a case of a 43-year-old cyclist presenting with pain and cyanosis of his toes due to an embolism to his left anterior tibial artery. The source of the embolus was found to be an ulcerated, endofibrotic plaque in his left common femoral artery.

METHODS

We performed an extensive literature search using the PubMed database and identified 60 results on endofibrosis. Eight articles described thrombosis relating to endofibrosis. None of the articles described an embolic phenomenon relating to endofibrosis. The following search terms were used: endofibrosis, embolic, emboli, embolism, "distal occlusion," cyanosis, thrombosis, and thrombus.

RESULTS

The patient is a 43-year-old male cyclist who presented with pain and cyanosis of his second and third toes on his left foot for 1 week. The affected toes had a dark-purple discoloration involving the tissue overlying the distal phalanges. Computed tomography angiography showed an abrupt occlusion of the left anterior tibial artery in the mid-calf with a non-calcified plaque in the left common femoral artery. There were no other signs of arterial disease. He underwent left common femoral endofibrosectomy with patch angioplasty that revealed an ulcerated endofibrotic plaque with mural thrombus.

CONCLUSIONS

This case demonstrates an unusual presentation of a rare clinical entity. While there have been previous reports of thrombosis associated with endofibrosis, to our knowledge this is the first reported case of endofibrosis presenting with embolic symptoms.

Dissecting aneurysm of common iliac artery in a long-distance runner

We present an unusual case of a long-distance runner suffering from acute dissection of a common iliac artery (CIA) aneurysm with endofibrotic lesions. He suffered from acute pelvic and abdominal pain after exercise. Computed tomography angiography confirmed the dissecting aneurysm of the left CIA without signs of rupture. After cutdown, resection of the CIA and iliac bifurcation as well as bypass grafting was performed. Histologic examination confirmed endofibrotic lesions without calcifications. Complicated iliac artery aneurysm could be the result of endofibrotic lesions. Clinicians should keep this in mind, even if physical examination findings and the ankle-brachial index are normal at rest and after exercise.