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Sharifi M, Snyder R, Sharifi I, White E. Long-term outcome of percutaneous endovascular stenting in external iliac artery endofibrosis. Vasc Med 2024; 29:256-264. [PMID: 38469820 DOI: 10.1177/1358863x241227476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/13/2024]
Abstract
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.
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Affiliation(s)
- Mohsen Sharifi
- Arizona Cardiovascular Consultants & Vein Clinic, Mesa, AZ, USA
- School of Osteopathic Medicine, A.T. Still University, Mesa, AZ, USA
| | - Robert Snyder
- Arizona Cardiovascular Consultants & Vein Clinic, Mesa, AZ, USA
| | - Iman Sharifi
- Arizona Cardiovascular Consultants & Vein Clinic, Mesa, AZ, USA
| | - Emily White
- Arizona Cardiovascular Consultants & Vein Clinic, Mesa, AZ, USA
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Sprynger M, Rigo F, Moonen M, Aboyans V, Edvardsen T, de Alcantara ML, Brodmann M, Naka KK, Kownator S, Simova I, Vlachopoulos C, Wautrecht JC, Lancellotti P. Focus on echovascular imaging assessment of arterial disease: complement to the ESC guidelines (PARTIM 1) in collaboration with the Working Group on Aorta and Peripheral Vascular Diseases. Eur Heart J Cardiovasc Imaging 2019; 19:1195-1221. [PMID: 30239635 DOI: 10.1093/ehjci/jey103] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 06/28/2018] [Indexed: 12/24/2022] Open
Abstract
The main goal of the present document is to provide a set of practical recommendations for ultrasound imagers who are interested in artery diseases or for physicians who intend to undertake vascular procedures. This is the first part of the work. It is dedicated to general principles of ultrasonography, cervicoencephalic, subclavian, aortoiliac and lower extremity arteries, abdominal aorta, and popliteal aneurysms. It also discusses miscellaneous items such as medial arterial calcinosis, arterial embolism, arteritis, arterial stents and bypasses, false aneurysms, aortic dissection, popliteal entrapment syndrome, and iliac endofibrosis.
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Affiliation(s)
- Muriel Sprynger
- Department of Cardiology, University of Liege Hospital, GIGA Cardiovascular Sciences, B35, Avenue de l'Hôpital, 1, Liege, Belgium
| | - Fausto Rigo
- Division of Cardiology, dell'Angelo Hospital Mestre-Venice, Venezia, Italy
| | - Marie Moonen
- Department of Cardiology, University of Liege Hospital, GIGA Cardiovascular Sciences, B35, Avenue de l'Hôpital, 1, Liege, Belgium
| | - Victor Aboyans
- Department of Cardiology, Dupuytren University Hospital, avenue Martin Luther King, 2, Limoges, France
| | - Thor Edvardsen
- Department of Cardiology, Oslo University Hospital, Sognsvannsveien, 20, OSLO, Norway
| | - Monica L de Alcantara
- Department of Cardiology, Americas Medical City Hospital, avenue Jorge Curi, 550, Rio de Janeiro, Brasil
| | - Marianne Brodmann
- Division of Angiology, Department of Internal Medicine, Medical University Graz, Auenbruggerplatz, 27, Graz, Austria
| | - Katerina K Naka
- 2nd Cardiology Department, University of Ioannina Medical School, University Campus, Loannina, Greece
| | - Serge Kownator
- Centre Cardiologique et Vasculaire, rue de Longwy, 12, Thionville, France
| | - Iana Simova
- Department of Cardiology, Acibadem City Clinic Cardiovascular Center, University Hospital, Okolovrasten pat Str, 127, Sofia, Bulgaria
| | | | - Jean-Claude Wautrecht
- Department of Vascular Diseases, Hôpital Erasme, route de Lennik, 808, Brussels, Belgium
| | - Patrizio Lancellotti
- Department of Cardiology, University of Liege Hospital, GIGA Cardiovascular Sciences, B35, Avenue de l'Hôpital, 1, Liege, Belgium
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Sullivan J, Bellas N, Thoens J, Gallagher J, Divinagracia T. Bilateral external iliac artery thrombosis due to endofibrosis in a 33-year-old female triathlete. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2019; 5:58-60. [PMID: 30911700 PMCID: PMC6416374 DOI: 10.1016/j.jvscit.2018.11.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 11/28/2018] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Jillian Sullivan
- Department of Vascular Surgery, Hartford Hospital, UConn Health, Hartford, Conn
| | - Nicholas Bellas
- University of Connecticut School of Medicine, UConn Health, Farmington, Conn
| | - Jonathan Thoens
- Department of Vascular Surgery, Hartford Hospital, UConn Health, Hartford, Conn
| | - James Gallagher
- Department of Vascular Surgery, Hartford Hospital, UConn Health, Hartford, Conn
| | - Thomas Divinagracia
- Department of Vascular Surgery, Hartford Hospital, UConn Health, Hartford, Conn.,University of Connecticut School of Medicine, UConn Health, Farmington, Conn
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Regus S, Almási-Sperling V, Janka R, Rother U, Lell M, Meyer A, Lang W. MRI to investigate iliac artery wall thickness in triathletes. PHYSICIAN SPORTSMED 2018. [PMID: 29522363 DOI: 10.1080/00913847.2018.1450060] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
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.
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Affiliation(s)
- Susanne Regus
- a Department of Vascular Surgery , University Hospital , Erlangen , Germany
| | | | - Rolf Janka
- b Institute of Radiology , University Hospital , Erlangen , Germany
| | - Ulrich Rother
- a Department of Vascular Surgery , University Hospital , Erlangen , Germany
| | - Michael Lell
- b Institute of Radiology , University Hospital , Erlangen , Germany
| | - Alexander Meyer
- a Department of Vascular Surgery , University Hospital , Erlangen , Germany
| | - Werner Lang
- a Department of Vascular Surgery , University Hospital , Erlangen , Germany
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Veraldi GF, Macrì M, Criscenti P, Scorsone L, Zingaretti CC, Gnoni M, Mezzetto L. Arterial endofibrosis in professional cyclists. G Chir 2016; 36:267-71. [PMID: 26888703 DOI: 10.11138/gchir/2015.36.6.267] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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DeCarlo CS, Spangler EL, Stableford JA. A Case of Endofibrosis Presenting with Embolic Symptoms in a 43-Year-Old Cyclist. Ann Vasc Surg 2016; 36:292.e5-292.e8. [PMID: 27423721 DOI: 10.1016/j.avsg.2016.03.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 02/26/2016] [Accepted: 03/11/2016] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Charles S DeCarlo
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA.
| | - Emily L Spangler
- Division of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
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D'Abate F, Paraskevas KI, Oates C, Palfreeman R, Hinchliffe RJ. Color Doppler Ultrasound Imaging in the Assessment of Iliac Endofibrosis. Angiology 2016; 68:225-232. [PMID: 27178720 DOI: 10.1177/0003319716649113] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Endofibrosis (EF) of the iliac arteries is a flow-limiting condition typically seen in highly trained endurance athletes. Thirty-seven athletes (74 limbs) were referred to our department with suspected EF. All patients had a pre- and postexercise color Doppler ultrasound (CDU) of the iliac arteries. Doppler waveform and peak systolic velocity (PSV) and end-diastolic velocity (EDV) were assessed pre- and postexercise. Endofibrosis was diagnosed with CDU in 24 athletes (29 limbs). Arterial wall and course abnormalities were detected at rest in 20 (67%) symptomatic limbs of athletes with and 4 (22%) symptomatic limbs of athletes without EF. Postexercise abnormal waveforms of the stenotic/damped type were seen in the iliac arteries in all 29 limbs of athletes diagnosed with EF. These waveform changes were accompanied by high PSV (>350 cm/s) and EDV (>150 cm/s), with (n = 10; 34%) or without (n = 19; 66%) the evidence of reduced arterial lumen caliber. Color Doppler ultrasound can be used to detect EF.
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Affiliation(s)
- Fabrizio D'Abate
- 1 St George's Vascular Institute, St George's Healthcare NHS Trust, London, United Kingdom
| | - Kosmas I Paraskevas
- 2 Northern Vascular Centre, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Crispian Oates
- 3 Department of Medical Physics, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Roger Palfreeman
- 1 St George's Vascular Institute, St George's Healthcare NHS Trust, London, United Kingdom
| | - Robert J Hinchliffe
- 1 St George's Vascular Institute, St George's Healthcare NHS Trust, London, United Kingdom
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Franco A, Rigberg DA, Ruehm SG. Bilateral Common Iliac Artery Endofibrosis in a Recreational Cyclist: Case Report and Review of the Literature. Ann Vasc Surg 2016; 35:203.e11-5. [PMID: 27263822 DOI: 10.1016/j.avsg.2016.02.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 02/06/2016] [Accepted: 02/08/2016] [Indexed: 10/21/2022]
Abstract
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.
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Affiliation(s)
- Arie Franco
- Department of Radiology, University of California, Los Angeles, Los Angeles, CA.
| | - David A Rigberg
- Department of Vascular Surgery, University of California, Los Angeles, Los Angeles, CA
| | - Stefan G Ruehm
- Department of Radiology, University of California, Los Angeles, Los Angeles, CA
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Abstract
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.
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Sharma AM, Norton PT, Zhu D. Conditions presenting with symptoms of peripheral arterial disease. Semin Intervent Radiol 2014; 31:281-91. [PMID: 25435652 DOI: 10.1055/s-0034-1393963] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
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.
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Affiliation(s)
- Aditya M Sharma
- Division of Cardiovascular Medicine, University of Virginia, Charlottesville, Virginia
| | - Patrick T Norton
- Department of Radiology, University of Virginia, Charlottesville, Virginia
| | - Daisy Zhu
- Medical Education, University Virginia School of Medicine, University of Virginia, Charlottesville, Virginia
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Rouvière O, Feugier P, Gutiérrez JP, Chevalier JM. Arterial Endofibrosis in Endurance Athletes: Angiographic Features and Classification. Radiology 2014; 273:294-303. [DOI: 10.1148/radiol.14130882] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
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.
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