Iliac artery endofibrosis is a rare condition that affects young endurance athletes, characterized by a non-atherosclerotic stenosis of the iliac artery.
It is a rare entity that affects highly trained endurance athletes, mostly cyclists and long-distance runners 4. The disease has also been reported in other sports players such as speed skaters, endurance runners, triathletes, rugby players, soccer players, cross-country skiers, and bodybuilders 3.
The main symptom is unilateral leg claudication triggered by a near-maximal effort in a young athlete 1. Physical examination is often unremarkable at rest.
The stenosis is progressive and can result in complete obstruction as a result of dissection or thrombosis 6.
The arterial stenosis consists of a focal intimal thickening made of loose connective tissue without atherosclerotic changes. The arterial endothelium, the media, and the adventitia are generally unaffected. The pathophysiology is unclear and the main etiologies include an excess vascular shear stress caused by supraphysiological blood flow, repeated arterial kinking and external compression by muscular hypertrophy 7.
The initial Doppler study is frequently normal except after high-intensity exercise, and it should not exclude the diagnosis.
The hip should be imaged in an extended and flexed position to allow identification of luminal stenosis as well as kinking of the arteries, which can be demonstrated on CT or MRI angiography.
The typical finding is a smooth or irregular eccentric stenosis, which starts after the common iliac bifurcation and extends about 5 cm in the external iliac artery 2.
Treatment and prognosis
Conservative management often fails to relieve symptoms and the desire of the patient to continue intensive sports often leads to invasive procedures 5.
Endofibrosectomy with vein patch angioplasty, saphenous vein bypass, shortening of the artery and release from the psoas muscle or from the inguinal ligament are the main surgical options 3.
History and etymology
It was first described in 1985 by Walder 8.
- 1 - Chevalier JM, Enon B, Walder J, Barral X, Pillet J, Megret A, Lhoste P, Saint-André JP, Davinroy M. Endofibrosis of the external iliac artery in bicycle racers: an unrecognized pathological state. (1986) Annals of vascular surgery. 1 (3): 297-303. doi:10.1016/S0890-5096(06)60123-4 - Pubmed
- 2 - Rouvière O, Feugier P, Gutiérrez JP, Chevalier JM. Arterial endofibrosis in endurance athletes: angiographic features and classification. (2014) Radiology. 273 (1): 294-303. doi:10.1148/radiol.14130882 - Pubmed
- 3 - Peach G, Schep G, Palfreeman R, Beard JD, Thompson MM, Hinchliffe RJ. Endofibrosis and kinking of the iliac arteries in athletes: a systematic review. (2012) European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery. 43 (2): 208-17. doi:10.1016/j.ejvs.2011.11.019 - Pubmed
- 4 - Ford SJ, Rehman A, Bradbury AW. External iliac endofibrosis in endurance athletes: a novel case in an endurance runner and a review of the literature. (2003) European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery. 26 (6): 629-34. doi:10.1016/j.ejvs.2003.08.003 - Pubmed
- 5 - Lucia Flors, Carlos Leiva-Salinas, Ugur Bozlar, Patrick T. Norton, Kenneth J. Cherry, Ahmed M. Housseini, Naren Gupta, Klaus D. Hagspiel. Imaging Evaluation of Flow Limitations in the Iliac Arteries in Endurance Athletes: Diagnosis and Treatment Follow-Up. (2012) American Journal of Roentgenology. 197 (5): W948-55. doi:10.2214/AJR.11.6547 - Pubmed
- 6 - TD Willson, E Revesz, FJ Podbielski, MJ Blecha. External iliac artery dissection secondary to endofibrosis in a cyclist. (2010) Journal of vascular surgery. 52 (1): 219. doi:10.1016/j.jvs.2010.02.259 - Pubmed
- 7 - Vink A, Bender MH, Schep G, van Wichen DF, de Weger RA, Pasterkamp G, Moll FL. Histopathological comparison between endofibrosis of the high-performance cyclist and atherosclerosis in the external iliac artery. (2008) Journal of vascular surgery. 48 (6): 1458-63. doi:10.1016/j.jvs.2008.07.057 - Pubmed
- 8 - Walder J, Mosimann F, Van Melle G, Mosimann R. [Iliac endofibrosis in 2 cycling racers]. (1985) Helvetica chirurgica acta. 51 (6): 793-5. Pubmed