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Van Langenhove K, Uijtterhaegen G, Moreels N, Randon C, Vermassen F. Iliac artery endofibrosis: diagnostic dilemna and treatment options. Acta Chir Belg 2024:1-7. [PMID: 38693887 DOI: 10.1080/00015458.2024.2348234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 04/21/2024] [Indexed: 05/03/2024]
Abstract
BACKGROUND External iliac artery endofibrosis (EIAE) is an uncommon pathology, predominantly occurring in cyclists, caused by thickening of the external iliac artery intima. Symptoms are exercise-dependent and typically consist of pain, muscle cramps and loss of strength in the affected limb at (sub)maximal effort. As other musculo-skeletal as well as conditional problems might cause similar complaints diagnosis is not always easy or straightforward. CASE SUMMARY AND DISCUSSION We reviewed four cases of (semi-)professional cyclists referred to our department in 2021 because of suspicion of EIAE. In all symptoms only occurred at (sub)maximal effort. All had lowering of ABI on the affected side at a dynamic stress test on the bike. Imaging using CTA, MRA or dynamic angiogram was abnormal in all patients, showing signs suspicious for endofibrosis but of different kind and at different locations. Open surgical repair was performed in all cases by a procedure tailored to the type of lesion. Two patients were treated by a saphenous vein patch angioplasty, in one patient a shortening of the vessel and end-to-end anastomosis was performed and in the fourth patient a spiral saphenous vein graft bypass was placed. Postoperative course was uneventful and exercise was resumed after four weeks in all patients. CONCLUSION Correct diagnosis is essential in the treatment of EIAE. A complete and multidisciplinary pathway should be followed to distinguish vascular from non-vascular causes. Correct lesion localization is crucial and besides CTA or MRA, more sophisticated techniques such as dynamic angiography or intravascular ultrasound might be needed.
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Affiliation(s)
| | | | - N Moreels
- University Hospital of Ghent, Belgium
| | - C Randon
- University Hospital of Ghent, Belgium
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Okamoto Y, Funasaki H, Tanaka K, Ohki T, Saito M. Exertional Lower Extremity Pain in a Triathlete Caused by External Iliac Artery Endofibrosis: A Case Report. JBJS Case Connect 2024; 14:01709767-202406000-00009. [PMID: 38608127 DOI: 10.2106/jbjs.cc.23.00685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2024]
Abstract
CASE This report describes a 25-year-old female professional triathlete with right external iliac artery endofibrosis (EIAE) that was definitively diagnosed on contrast-enhanced magnetic resonance images obtained immediately after treadmill running. The EIAE was treated by percutaneous transluminal angioplasty. By 8 weeks after surgery, she had no symptoms of claudication or pain in the right thigh after a 1-hour running session. There has been no recurrence in 1 year postoperatively. CONCLUSION EIAE is a rare condition and difficult to diagnose in a timely manner because symptoms and radiographic imaging features appear only during intense exercise. Our patient was successfully treated with percutaneous transluminal angioplasty.
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Affiliation(s)
- Yasufumi Okamoto
- Department of Sports and Wellness Clinic, The Jikei University School of Medicine, Tokyo, Japan
| | - Hiroki Funasaki
- Department of Sports and Wellness Clinic, The Jikei University School of Medicine, Tokyo, Japan
| | - Kota Tanaka
- Department of Sports and Wellness Clinic, The Jikei University School of Medicine, Tokyo, Japan
| | - Takao Ohki
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Mitsuru Saito
- Department of Sports and Wellness Clinic, The Jikei University School of Medicine, Tokyo, Japan
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Regus S, Schoeffl I, Knetsch J, Schoeffl V, Haase K. [Iliac endofibrosis in high-performance sports: an interdisciplinary diagnostic challenge]. SPORTVERLETZUNG SPORTSCHADEN : ORGAN DER GESELLSCHAFT FUR ORTHOPADISCH-TRAUMATOLOGISCHE SPORTMEDIZIN 2023; 37:171-181. [PMID: 38048810 DOI: 10.1055/a-2133-9702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/06/2023]
Abstract
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.
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Nakase M, Yahagi K, Komiyama K, Nemoto S, Kawabe A, Hosoda N, Horiuchi Y, Asami M, Yuzawa H, Tanaka J, Aoki J, Mori M, Tanabe K. Delayed rupture of the iliac artery after endovascular therapy. J Cardiol Cases 2023; 27:237-240. [PMID: 37180218 PMCID: PMC10173389 DOI: 10.1016/j.jccase.2023.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 01/04/2023] [Accepted: 01/24/2023] [Indexed: 02/11/2023] Open
Abstract
Iliac artery rupture during endovascular therapy (EVT) is a life-threatening complication requiring prompt diagnosis and treatment. However, delayed rupture of the iliac artery after EVT is rare, and its predictive value remains unknown. Herein, we present the case of a 75-year-old woman who developed delayed iliac artery rupture 12 h after balloon angioplasty and placement of a self-expandable stent in the left iliac artery. Hemostasis was achieved with a covered stent graft. However, the patient died of hemorrhagic shock. From the review of previous case reports and the pathological findings of the current case, increased radial force due to overlapping stent and kinking of the iliac artery may be associated with delayed iliac artery rupture. Learning objective Delayed iliac artery rupture after endovascular therapy is rare but with a poor prognosis. Hemostasis can be achieved using a covered stent; however, the outcome could be fatal. Based on pathological findings and previous case reports, increased radial force at the stent site and kinking of the iliac artery may be associated with delayed iliac artery rupture. Self-expandable stent probably should not be overlapped at the site where kinking is likely to occur, even if long stenting is needed.
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Surgical shortening of lengthened iliac arteries in endurance athletes: Short-term and long-term satisfaction. J Vasc Surg 2023; 77:588-598.e3. [PMID: 36334847 DOI: 10.1016/j.jvs.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 09/30/2022] [Accepted: 10/03/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Endurance athletes are prone to develop flow limitations in iliac arteries (FLIA). Especially in cyclists and ice speed skaters, excessive hemodynamic loading coupled with hip hyperflexion may cause kinking in lengthened iliac arteries necessitating surgical correction. This study investigated the short-term (≤1.5 years) and long-term (≥5 years) satisfaction of operative shortening of the iliac artery in endurance athletes. METHODS All patients who were diagnosed and operated for FLIA owing to lengthened and kinked iliac arteries between 1997 and 2015 in one center were analyzed. Short-term follow-up consisted of an incremental maximal cycling test, ankle-brachial index with flexed hips, echo-Doppler examination with peak systolic velocity measurements and contrast-enhanced magnetic resonance angiography before and 6 to 18 months after surgery. Both short- and long-term satisfaction were assessed using questionnaires. RESULTS A total of 83 patients (90 operated legs; 96.7% males; median age of 34 years at the time of surgery; interquartile range [IQR], 29-47) were analyzed. In the short-term, 87.5% reported symptom reduction with an 86.4% overall satisfaction rate. Symptom-free cycling improved from 272 ± 84 W to 384 ± 101 W (P < .001), whereas the maximal workload increased from 419 ± 72 W to 428 ± 67 W (P = .01). The ankle-brachial index with flexed hips increased from 0.55 (IQR, 0.45-0.65) to 0.62 (IQR, 0.52-0.74; P = .008), and the peak systolic velocity measured with hips flexed decreased from 2.50 m/s (IQR, 1.77-3.13 m/s) to 1.57 m/s (IQR, 1.20-2.04 m/s; P < .001). After a median of 12 years (IQR, 9.0-15.4 years), symptoms were still decreased in 84.1% of patients with an 81.2% overall satisfaction rate (79.5% response rate). Three patients needed a reintervention (recurrent FLIA, n = 2; failure, n = 1). CONCLUSIONS Operative shortening of a lengthened and kinked iliac artery causing FLIA is successful both in the short- and long-term.
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Fisher AT, Tran K, Dossabhoy SS, Sorondo S, Fereydooni A, Lee JT. Anatomic factors contributing to external iliac artery endofibrosis in high performance athletes. Ann Vasc Surg 2022; 87:181-187. [PMID: 35654289 DOI: 10.1016/j.avsg.2022.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 04/12/2022] [Accepted: 05/10/2022] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- Andrea T Fisher
- Division of Vascular Surgery, Department of Surgery, Stanford University, Stanford, CA.
| | - Kenneth Tran
- Division of Vascular Surgery, Department of Surgery, Stanford University, Stanford, CA.
| | - Shernaz S Dossabhoy
- Division of Vascular Surgery, Department of Surgery, Stanford University, Stanford, CA.
| | - Sabina Sorondo
- Division of Vascular Surgery, Department of Surgery, Stanford University, Stanford, CA.
| | - Arash Fereydooni
- Division of Vascular Surgery, Department of Surgery, Stanford University, Stanford, CA.
| | - Jason T Lee
- Division of Vascular Surgery, Department of Surgery, Stanford University, Stanford, CA.
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Wang S, Zhou T, Yu N, Liu R. An extremely rare disconnection of the external iliac artery and novel collateral remodeling in an endometrial stromal sarcoma woman. BMC Womens Health 2022; 22:160. [PMID: 35545775 PMCID: PMC9092857 DOI: 10.1186/s12905-022-01746-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 04/29/2022] [Indexed: 11/25/2022] Open
Abstract
Background Injury to the external iliac artery can have serious consequences and can be extremely challenging for surgeons. Here, we report a patient with bizarre disconnection of the external iliac artery during a laparoscopic operation. Case presentation On May 27, 2020, during a laparoscopic pelvic lymphadenectomy operation to treat endometrial stromal sarcoma, we encountered an unusual anatomy: abnormal disconnection of the left external iliac artery in a 26-year-old female patient. The proximal and distal ends of the left external iliac artery demonstrated old narrowing without active bleeding, and the distance between the two disconnected ends was more than 3 cm. The scenario was surprising to all the staff in the operating theater. After a comprehensive assessment of skin temperature, arterial pulsation and arterial blood flow, a multidisciplinary team determined that collateral circulation of the left lower limb had been established and could meet the blood supply of the lower limbs, which was also confirmed three times by computed tomography angiography and Doppler ultrasound of the blood vessels in the abdomen and lower limbs. Sixteen months after the operation, the patient had no obvious abnormality, and the daily activities of the left lower limb were not affected. Follow-up after treatment for the patient is still in progress. Conclusions We describe the details of the whole case of disconnection of the external iliac artery. We hope to summarize the experience and lessons learned through this case and a relevant literature review to improve the safety and orderliness of our future clinical work.
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Affiliation(s)
- Shixuan Wang
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China
| | - Ting Zhou
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China
| | - Nan Yu
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China
| | - Ronghua Liu
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China.
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Hooff M, Meijer EJ, Scheltinga MRM, Savelberg HHCM, Schep G. Test–retest reliability of skeletal muscle oxygenation measurement using near‐infrared spectroscopy during exercise in patients with sport‐related iliac artery flow limitation. Clin Physiol Funct Imaging 2022; 42:114-126. [PMID: 35075811 PMCID: PMC9306874 DOI: 10.1111/cpf.12738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 12/21/2021] [Indexed: 11/30/2022]
Abstract
The ankle‐brachial index is an accurate tool for detecting claudication in atherosclerotic patients. However, this technique fails to identify subtle flow limitations of the iliac arteries (FLIA) in endurance athletes. Near‐infrared spectroscopy (NIRS) is a noninvasive technique that measures skeletal muscle tissue oxygenation status. The aim of the present study is to examine the absolute and relative test–retest reliability of NIRS and evaluate its potential as a diagnostic tool in FLIA. NIRS‐derived exercise variables were analyzed during exercise and recovery in FLIA 17 patients and 19 healthy controls. The relative reliability of absolute variables (such as the maximal value) were slight to yet predominantly substantial (intraclass correlation coefficient [ICC], ICC range: 0.06–0.76) with good to excellent absolute reliability (absolute limits of agreement [ALoA], ALoA range: 0.8 ± 10.2 to 0.7 ± 13.1; coefficient of variation [CV], CV range: 5%–11%). Absolute values encompassing signal amplitudes showed moderate to almost perfect relative reliability (ICC range: 0.51–0.89) and poor to good absolute reliability (ALoA range: −1.3 ± 7.0 to −2.5 ± 15.7; CV range: 15%–32%). Kinetic variables showed moderate to almost perfect relative reliability for most recovery kinetics variables (ICC range: 0.54–0.86) with fair to good absolute reliability (ALoA range: 0.4 ± 12.2 to 3.9 ± 37.9; CV range: 18%–27%). Particularly, kinetic variables showed significant differences between patients and healthy subjects. NIRS is found to be a reliable method for examining muscle tissue oxygenation variables. Given the significant differences in especially recovery kinetics between normal subjects and patients, NIRS may contribute to diagnosing FLIA in endurance athletes.
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Affiliation(s)
- Martijn Hooff
- Department of Sports and Exercise Máxima Medical Centre Veldhoven Noord‐Brabant The Netherlands
- Department of Movement and Nutrition Sciences, Faculty of Health, Medicine and Life Sciences Maastricht University Maastricht Maastricht The Netherlands
| | - Eduard J. Meijer
- Department of Clinical Physics Máxima Medical Centre Veldhoven Noord‐Brabant The Netherlands
| | - Marc R. M. Scheltinga
- Department of Clinical Physics Máxima Medical Centre Veldhoven Noord‐Brabant The Netherlands
- Department of Vascular Surgery Máxima Medical Centre Veldhoven Noord‐Brabant The Netherlands
| | - Hans H. C. M. Savelberg
- Department of Movement and Nutrition Sciences, Faculty of Health, Medicine and Life Sciences Maastricht University Maastricht Maastricht The Netherlands
| | - Goof Schep
- Department of Sports and Exercise Máxima Medical Centre Veldhoven Noord‐Brabant The Netherlands
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Abraham P, Lecoq S, Hersant J, Henni S. Arterial claudication. VASCULAR INVESTIGATION AND THERAPY 2022. [DOI: 10.4103/2589-9686.360872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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10
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Bilman V, Rinaldi E, Sanvito F, Melissano G, Chiesa R. External iliac artery endofibrosis in an elite female endurance cyclist. J Vasc Bras 2021; 20:e20200122. [PMID: 34093684 PMCID: PMC8147885 DOI: 10.1590/1677-5449.200122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
External iliac artery endofibrosis is a rare pathology that affects high-level endurance athletes, especially cyclists. Classical symptoms include pain, loss of power, and/or cramp in the affected limb while training at maximal effort. The patient's lack of atherosclerotic risk factors makes clinical suspicion of arteriopathy challenging. Moreover, the best management of such patients is still a subject of discussion. We report the case of a 36-year-old professional female endurance cyclist who presented with lower extremity pain during training. Right external iliac artery endofibrosis was diagnosed and the patient underwent surgical treatment. At two-months follow-up, she reported significant improvement in symptoms. This case highlights the importance of diagnosing peripheral vascular disease in young patients and athletes, who do not fit the ordinary profile of patients with atherosclerotic risk factors.
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Affiliation(s)
- Victor Bilman
- "Vita-Salute" University, Scientific Institute H. San Raffaele, Division of Vascular Surgery, Milan, Italy
| | - Enrico Rinaldi
- "Vita-Salute" University, Scientific Institute H. San Raffaele, Division of Vascular Surgery, Milan, Italy
| | - Francesca Sanvito
- "Vita-Salute" University, Scientific Institute H. San Raffaele, Division of Anatomic Pathology, Milan, Italy
| | - Germano Melissano
- "Vita-Salute" University, Scientific Institute H. San Raffaele, Division of Vascular Surgery, Milan, Italy
| | - Roberto Chiesa
- "Vita-Salute" University, Scientific Institute H. San Raffaele, Division of Vascular Surgery, Milan, Italy
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Gähwiler R, Hirschmüller A, Grumann T, Isaak A, Thalhammer C. Exercise induced leg pain due to endofibrosis of external iliac artery. VASA 2020; 50:92-100. [PMID: 32930655 DOI: 10.1024/0301-1526/a000909] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
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.
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Affiliation(s)
- Roman Gähwiler
- Department of Angiology, University Hospital, Cantonal Hospital Aarau, Switzerland.,Department of Health & Medicine, Danube University Krems, Austria
| | - Anja Hirschmüller
- ALTIUS Swiss Sportmed Center AG, Rheinfelden, Switzerland.,Department of Orthopedics and Trauma Surgery, Medical Center, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Germany
| | | | - Andrej Isaak
- Department of Vascular Surgery, Cantonal Hospital Aarau, Switzerland
| | - Christoph Thalhammer
- Department of Angiology, University Hospital, Cantonal Hospital Aarau, Switzerland
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12
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Cyclist Endofibrosis (Exercise-Induced Arterial Endofibrosis) Treated by Drug-Coated Balloon Angioplasty. Case Rep Vasc Med 2020; 2020:4290271. [PMID: 32724699 PMCID: PMC7366215 DOI: 10.1155/2020/4290271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Accepted: 06/24/2020] [Indexed: 11/17/2022] Open
Abstract
Exercise-induced arterial endofibrosis is an uncommon entity that is most frequently identified in high-performance athletes, especially cyclists. We present this disease in a male professional cyclist of 22 years of age. The course of his condition, clinical manifestations, modalities of investigation, and a nonprecedent treatment plan are demonstrated.
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Perrier L, Feugier P, Goutain-Majorel C, Girouin N, Boutier R, Papillard M, Bedel M, Rabilloud M, Rouvière O. Arterial endofibrosis in endurance athletes: Prospective comparison of the diagnostic accuracy of intra-arterial digital subtraction angiography and computed tomography angiography. Diagn Interv Imaging 2020; 101:463-471. [PMID: 32245721 DOI: 10.1016/j.diii.2020.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 03/08/2020] [Accepted: 03/10/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE To prospectively compare the diagnostic capabilities of computed tomography angiography (CTA) to those of digital subtraction angiography (DSA) in endurance athletes with suspicion of arterial endofibrosis. MATERIALS AND METHODS Forty-five athletes (39 men, 6 women; median age: 30 years, interquartile range: 23-42 years) prospectively underwent DSA and CTA without (n=5) or with (n=40) electrocardiogram gating. DSA was interpreted by a single expert (experience of 15 years). CTA was independently interpreted by three other readers (experience of 5-8 years). Readers assessed the presence and degree of stenoses on iliac and femoral arteries and the overall diagnosis (negative, uncertain, positive) of endofibrosis at the limb level. Sensitivities and specificities of DSA and CTA were estimated at the limb level using histological findings and long-term follow-up as reference, and compared using the McNemar test. RESULTS For diagnosing and quantifying stenoses, concordance between DSA and CTA was moderate-to-good for common and external iliac arteries, moderate for lateral circumflex arteries and poor-to-moderate for the other branches of the deep femoral artery. It was good for all readers for the overall diagnosis of endofibrosis. After long-term follow-up (median, 95 months; interquartile range: 7-109 months), DSA sensitivity and specificity were respectively 88.6% (39/44; 95% confidence interval [CI]: 76-95%) and 75% (24/32; 95% CI: 57.9-86.7%); CTA sensitivity and specificity were respectively 88.6% (39/44; 95% CI: 76-95%; P>0.99) and 84.4% (27/32; 95% CI: 68.2-93.1%; P=0.51), 86.3% (38/44; 95% CI: 73.3-93.6%; P>0.99) and 75% (24/32; 95% CI: 57.9-86.7%; P>0.99), and 84.1% (37/44; 95% CI: 70.6-92.1%; P=0.68) and 75% (24/32; 95% CI: 57.9-86.7%; P>0.99) for the three readers. CONCLUSION CTA shows performances similar to those of DSA in predicting the long-term diagnosis of endofibrosis in endurance athletes with suggestive symptoms.
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Affiliation(s)
- L Perrier
- Service de radiologie urinaire et vasculaire, Hôpital Edouard-Herriot, Hospices Civils de Lyon, Pavillon B, 5, place d'Arsonval, 69437 Lyon cedex 03, France; Faculté de médecine Lyon Est, Université de Lyon, Université Lyon 1, 69003 Lyon, France
| | - P Feugier
- Service de chirurgie vasculaire, Centre hospitalier Lyon Sud, Hospices civils de Lyon, 69495 Pierre-Bénite, France
| | - C Goutain-Majorel
- Service de physique médicale et radioprotection, centre hospitalier Lyon Sud, Hospices civils de Lyon, 69495 Pierre-Bénite, France
| | - N Girouin
- Norimagerie, 69300 Caluire et Cuire, France
| | - R Boutier
- Norimagerie, 69300 Caluire et Cuire, France
| | - M Papillard
- Service de radiologie, Centre hospitalier de Mâcon, 71018 Mâcon, France
| | - M Bedel
- Service de biostatistique-bioinformatique, Pôle santé publique, Hospices Civils de Lyon, 69003 Lyon, France
| | - M Rabilloud
- Faculté de médecine Lyon Est, Université de Lyon, Université Lyon 1, 69003 Lyon, France; Service de biostatistique-bioinformatique, Pôle santé publique, Hospices Civils de Lyon, 69003 Lyon, France; CNRS, UMR 5558, équipe biostatistiques santé, laboratoire de biométrie et biologie évolutive, 69100 Villeurbanne, France
| | - O Rouvière
- Service de radiologie urinaire et vasculaire, Hôpital Edouard-Herriot, Hospices Civils de Lyon, Pavillon B, 5, place d'Arsonval, 69437 Lyon cedex 03, France; Faculté de médecine Lyon Est, Université de Lyon, Université Lyon 1, 69003 Lyon, France.
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Cai TY, Rajendran S, Robinson D. Functional magnetic resonance angiography in the diagnosis of iliac artery endofibrosis in an endurance runner. BMJ Case Rep 2019; 12:12/11/e232112. [PMID: 31780606 DOI: 10.1136/bcr-2019-232112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
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.
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Affiliation(s)
- Tommy Ye Cai
- Department of Vascular Surgery, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia .,Faculty of Health and Medicine, The University of Sydney, Sydney, New South Wales, Australia
| | - Saissan Rajendran
- Department of Vascular Surgery, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,Faculty of Medicine, University of New South Wales, Kensington, New South Wales, Australia
| | - David Robinson
- Department of Vascular Surgery, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
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15
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Lindo FA, Lee JT, Morta J, Ross E, Shub Y, Wilson C. Diagnosis and management of external iliac endofibrosis: A case report. JOURNAL OF VASCULAR NURSING 2019; 37:86-90. [PMID: 31155167 DOI: 10.1016/j.jvn.2018.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 11/29/2018] [Accepted: 11/30/2018] [Indexed: 10/27/2022]
Abstract
External iliac artery endofibrosis is an uncommon, nonatherosclerotic disease seen in endurance cyclists. It is poorly identified by providers. These otherwise healthy patients usually present with symptoms of arterial insufficiency, such as thigh or buttock pain, loss of power, or weakness occurring during strenuous exercises. These symptoms subside rapidly with rest. As these patients lack traditional risk factors of peripheral artery disease, their symptoms are often overlooked or are attributed to other etiologies, resulting in mismanagement and delayed treatment. In this case study, we report our experience with the successful management of a 48-year-old male who is a longstanding, avid cyclist. He self-referred to our institution after extensive research of providers familiar with his problem and at the recommendation of other cyclists with similar experiences. The patient underwent a successful left external iliac to common femoral artery endarterectomy and patch angioplasty. Three months after operation, he returned to cycling and, for the most part, has remained without symptoms.
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Affiliation(s)
- Fae A Lindo
- Stanford Health Care, Heart and Vascular Clinics, 300 Pasteur Dr. Boswell Bldg. A32, Stanford, CA 94305, USA.
| | - Jason T Lee
- Stanford Health Care, Heart and Vascular Clinics, 300 Pasteur Dr. Boswell Bldg. A32, Stanford, CA 94305, USA
| | - Jocelyn Morta
- Stanford Health Care, Heart and Vascular Clinics, 300 Pasteur Dr. Boswell Bldg. A32, Stanford, CA 94305, USA
| | - Elsie Ross
- Stanford Health Care, Heart and Vascular Clinics, 300 Pasteur Dr. Boswell Bldg. A32, Stanford, CA 94305, USA
| | - Yelena Shub
- Stanford Health Care, Heart and Vascular Clinics, 300 Pasteur Dr. Boswell Bldg. A32, Stanford, CA 94305, USA
| | - Christina Wilson
- Stanford Health Care, Heart and Vascular Clinics, 300 Pasteur Dr. Boswell Bldg. A32, Stanford, CA 94305, USA
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16
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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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17
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Pedal power measurement as a diagnostic tool for functional vascular problems. Clin Biomech (Bristol, Avon) 2019; 61:211-216. [PMID: 30597482 DOI: 10.1016/j.clinbiomech.2018.12.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 12/17/2018] [Accepted: 12/20/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Cyclists with flow limitations in the iliac arteries complain of pain and loss of power. To investigate whether pedal power measurement has added value in diagnosing the underlying cause of flow limitations in the iliac arteries, we explored the sensitivity and specificity of various pedal power measurement variables. Moreover, it was assessed what the added value of pedal power measurement is compared to diagnosis based on the conventional ankle-brachial blood pressure index. METHODS 25 healthy participants and 45 patients with unilateral arterial flow limitations were recruited. Participants received Echo-Doppler examination to determine the condition of the iliac arteries. Subsequently, participants performed a maximal cycle ergometer test. During the cycling test the exerted left and right pedal power was measured. From these measurements several variables were derived to diagnose arterial flow limitations. A receiver operating characteristics curve based on a predicted cross-validated model was used to select the variable with the highest predictive value and its cut-off value. FINDINGS The mean power difference between both legs relative to the exerted power at 95% of the maximal power showed the best predictive value with a sensitivity of 0.76 and a specificity of 0.88. Combining the pedal power measurement and ankle-brachial blood pressure index resulted in a sensitivity of 0.91 and a specificity of 0.88. INTERPRETATION Pedal power measurement improves sensitivity of diagnosis of iliac artery flow limitations, without increasing the burden of clinical investigation to the patients.
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18
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Protease-activated receptors are potential regulators in the development of arterial endofibrosis in high-performance athletes. J Vasc Surg 2018; 69:1243-1250. [PMID: 30314721 DOI: 10.1016/j.jvs.2018.05.220] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 05/14/2018] [Indexed: 11/21/2022]
Abstract
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.
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19
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Wuarin L, Verdon G, Pollorsi G, Huber C, Murith N, Mugnai D. External Iliac Artery Endofibrosis in a Female Cyclist: A Case Report. Ann Vasc Surg 2018; 55:310.e1-310.e4. [PMID: 30287298 DOI: 10.1016/j.avsg.2018.07.053] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 06/18/2018] [Accepted: 07/07/2018] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Lydia Wuarin
- Département de Chirurgie, Service de Chirurgie Cardio-Vasculaire, Hôpitaux Universitaires de Genève, Geneva, Switzerland.
| | - Gabriel Verdon
- Département de Chirurgie, Service de Chirurgie Vasculaire, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Gaia Pollorsi
- Département de Chirurgie, Service de Chirurgie Vasculaire, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Christoph Huber
- Département de Chirurgie, Service de Chirurgie Cardio-Vasculaire, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Nicolas Murith
- Département de Chirurgie, Service de Chirurgie Cardio-Vasculaire, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Damiano Mugnai
- Département de Chirurgie, Service de Chirurgie Cardio-Vasculaire, Hôpitaux Universitaires de Genève, Geneva, Switzerland
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20
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Khan A, Al-Dawoud M, Salaman R, Al-Khaffaf H. Management of Endurance Athletes with Flow Limitation in the Iliac Arteries: A Case Series. EJVES Short Rep 2018; 40:7-11. [PMID: 30101198 PMCID: PMC6083816 DOI: 10.1016/j.ejvssr.2018.06.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Revised: 06/15/2018] [Accepted: 06/18/2018] [Indexed: 10/28/2022] Open
Abstract
Introduction Vascular surgeons increasingly encounter flow limitation of iliac arteries (FLIA) in endurance athletes. An experience of managing this condition is reported. Report This is a retrospective cohort analysis of prospectively collected data at a single vascular centre. Between 2001 and 2017, 12 athletes with exercise induced pain underwent investigation and assessment. Patients with significant radiological findings (iliac kinking ± stenosis demonstrated on duplex ultrasound or catheter angiography) and dynamic flow changes (marked reduction in ankle brachial pressure indices following exertion, or increase in the common iliac artery peak systolic velocity during hip flexion on duplex) underwent surgery after trialling conservative management; the majority were open iliac shortening procedures. Patients with radiological findings, but no dynamic flow changes were managed conservatively. All patients were followed up. Discussion There were 10 men and two women with a median age of 40 years. Nine patients had iliac kinking (five in isolation, four associated with stenosis), two had stenosis, and one had no iliac disease. Eight patients had severe symptoms (absolute loss of power on maximal exertion) demonstrated dynamic post-exertional flow changes. Seven patients successfully underwent surgery, returning to their sport at similar intensity. One procedure was abandoned owing to severe adhesions from a prior procedure. This patient subsequently changed sport. Three patients with mild symptoms (two had reduction in power at maximal intensity, one was an incidental finding) and who demonstrated no clinical signs of FLIA continued their sport at a lower intensity. Kinking of the iliac arteries in athletes can occur with or without of iliac stenosis. Patients with the most severe iliac symptoms demonstrate dynamic post-exertional flow limitation and may benefit from surgery following a period of conservative management. Patients who have milder symptoms and no dynamic exercise flow limitations can be managed conservatively.
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Affiliation(s)
- Assad Khan
- Department of Vascular Surgery, East Lancashire Hospitals NHS Trust, Royal Blackburn Teaching Hospital, Blackburn, UK
| | - Marwan Al-Dawoud
- Department of Vascular Surgery, East Lancashire Hospitals NHS Trust, Royal Blackburn Teaching Hospital, Blackburn, UK
| | - Robert Salaman
- Department of Vascular Surgery, East Lancashire Hospitals NHS Trust, Royal Blackburn Teaching Hospital, Blackburn, UK
| | - Haytham Al-Khaffaf
- Department of Vascular Surgery, East Lancashire Hospitals NHS Trust, Royal Blackburn Teaching Hospital, Blackburn, UK
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21
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Wille J, de Jong JR, Moll FL, Hammacher ER, van der Zwan A, Fick TE, Ugahary F. Endofibrosis of the External Iliac Artery in Sportsmen Clinical Review and Four New Cases. ACTA ACUST UNITED AC 2016. [DOI: 10.1177/153857449803200405] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Endofibrosis of the external iliac artery is an unusual condition associated with competition cyclists. There seems to be a good prognosis after surgical therapy, consisting of endarterectomy and vein patching in combination with resection if the artery is lengthened. However, absence of well-documented long-term follow-up studies makes surgical treatment controversial. The authors describe four new patients with endofibrosis of the external iliac artery (EIA) with a review of relevant literature.
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Affiliation(s)
- Jan Wille
- Department of Surgery, St. Antonius Hospital, Nieuwegein
| | | | - Frans L. Moll
- Department of Surgery, St. Antonius Hospital, Nieuwegein
| | | | | | - Tom E. Fick
- Department of Surgery, University Hospital Utrect
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22
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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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23
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Hinchliffe R, D'Abate F, Abraham P, Alimi Y, Beard J, Bender M, Björck M, Edmundson C, Fernandez Garcia B, Cherry K, Álvarez Fernández L, Feugier P, Lee J, Palfreeman R, Passfield L, Peach G, Ricco JB, Rimpler H, Roake J, Rouviere O, Schep G, Spark I, Schumacher Y, Zierler R. Diagnosis and Management of Iliac Artery Endofibrosis: Results of a Delphi Consensus Study. Eur J Vasc Endovasc Surg 2016; 52:90-8. [DOI: 10.1016/j.ejvs.2016.04.004] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 04/06/2016] [Indexed: 11/25/2022]
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24
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Maree AO, Ashequl Islam M, Snuderl M, Lamuraglia GM, Stone JR, Olmsted K, Rosenfield KA, Jaff MR. External iliac artery endofibrosis in an amateur runner: hemodynamic, angiographic, histopathological evaluation and percutaneous revascularization. Vasc Med 2016; 12:203-6. [PMID: 17848477 DOI: 10.1177/1358863x07080844] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Andrew O Maree
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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25
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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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26
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Abstract
Atherosclerotic peripheral artery disease is the most common cause of intermittent claudication. Nonatherosclerotic peripheral artery disease is a heterogeneous collection of diseases affecting the extracoronary arteries which is not due to atherosclerosis. These diseases include, but are not limited to, popliteal artery entrapment syndrome, cystic adventitial disease, external iliac endofibrosis, and thromboangiitis obliterans. Due to its relatively low prevalence, nonatherosclerotic peripheral artery disease may be misdiagnosed leading to the mismanagement of potentially treatable conditions. The proper and timely diagnosis of these conditions is paramount to the prevention of adverse outcomes as treatments widely vary. The diagnostic approach to patients presenting with intermittent claudication must take into account both atherosclerotic as well as nonatherosclerotic causes of peripheral artery disease making the differential vital to clinical practice.
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Affiliation(s)
- Ari J Mintz
- Internal Medicine, Lahey Hospital and Medical Center, 41 Mall Road, Burlington, MA, 01805, USA,
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27
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Regus S, Söder S, Lang W. Dissecting aneurysm of common iliac artery in a long-distance runner. J Vasc Surg Cases 2016; 2:4-6. [PMID: 31724633 PMCID: PMC6849994 DOI: 10.1016/j.jvsc.2015.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Accepted: 11/20/2015] [Indexed: 11/28/2022] Open
Abstract
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.
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Affiliation(s)
- Susanne Regus
- Department of Vascular Surgery, University Hospital, Erlangen, Germany
| | - Stephan Söder
- Department of Pathology, University Hospital, Erlangen, Germany
| | - Werner Lang
- Department of Vascular Surgery, University Hospital, Erlangen, Germany
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28
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Nekkanti M, Sivagnanam K, Bhat PSS. An Endovascular Approach to Spontaneous Isolated Acute Iliac Dissecting Aneurysm with Contained Rupture. Ann Vasc Surg 2015; 31:210.e5-8. [PMID: 26658090 DOI: 10.1016/j.avsg.2015.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Revised: 09/28/2015] [Accepted: 09/29/2015] [Indexed: 11/26/2022]
Abstract
Acute spontaneous isolated common and external iliac dissection with aneurysm is a very rare entity involving high morbidity and mortality, with only few reports in literature. If not treated promptly, they have high morbidity or mortality in case they rupture. We report a case of similar dissection with aneurysmal formation managed with percutaneous stent-graft placement. This is a unique case where aorta was not involved and patient presented to us in stable hemodynamic status in spite of a contained rupture at the dissected site.
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Affiliation(s)
- Muralikrishna Nekkanti
- Department of Cardiac Surgery, Sri Jayadeva Institute of Cardiovascular Sciences & Research, Bangalore, India
| | - Karthikeyan Sivagnanam
- Department of Cardiac Surgery, Sri Jayadeva Institute of Cardiovascular Sciences & Research, Bangalore, India.
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29
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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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30
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Lindner D, Agar G, Domb BG, Beer Y, Shub I, Mann G. An unusual case of leg pain in a competitive cyclist: a case report and review of the literature. Sports Health 2014; 6:492-6. [PMID: 25364481 PMCID: PMC4212352 DOI: 10.1177/1941738114524160] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
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.
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Affiliation(s)
| | - Gabriel Agar
- Department of Orthopaedics, Assaf Harofeh Medical Center, Zerifin, Israel
| | - Benjamin Gilbert Domb
- American Hip Institute, Westmont, Illinois ; Hinsdale Orthopaedics, Hinsdale, Illinois ; Loyola University of Chicago, Chicago, Illinois
| | - Yiftah Beer
- Department of Orthopaedics, Assaf Harofeh Medical Center, Zerifin, Israel
| | - Idit Shub
- Meir Medical Center, Kfar Saba, Israel
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31
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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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32
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33
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Green BL, Bailey MA, Bridge KI, Scott DJA. Images in vascular medicine. External iliac artery endofibrosis in an amateur runner. Vasc Med 2014; 19:419-20. [PMID: 25080463 DOI: 10.1177/1358863x14544401] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Ben L Green
- Multidisciplinary Cardiovascular Research Centre, University of Leeds, Leeds, UK
| | - Marc A Bailey
- Multidisciplinary Cardiovascular Research Centre, University of Leeds, Leeds, UK The Leeds Vascular Institute at The Leeds General Infirmary, Leeds, UK
| | - Katherine I Bridge
- Multidisciplinary Cardiovascular Research Centre, University of Leeds, Leeds, UK The Leeds Vascular Institute at The Leeds General Infirmary, Leeds, UK
| | - D Julian A Scott
- Multidisciplinary Cardiovascular Research Centre, University of Leeds, Leeds, UK The Leeds Vascular Institute at The Leeds General Infirmary, Leeds, UK
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34
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Abstract
MR angiography is a powerful tool in evaluating anatomy and pathology when applied to the male pelvis. MR angiography produces high-quality images of the arterial system approaching the resolution of CT angiography, without ionizing radiation. Additional advantages include the ability to obtain angiographic images in the absence of contrast material with non-contrast-enhanced MR angiographic techniques. Blood pool contrast agents, such as gadofosveset, have significantly improved the quality of venous system imaging. Steady state imaging with blood pool contrast agents allows for acquisition of superior-quality high-resolution images and other time-intensive techniques.
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Affiliation(s)
- Patrick D Sutphin
- Division of Interventional Radiology, Department of Radiology, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-8834, USA
| | - Sanjeeva P Kalva
- Division of Interventional Radiology, Department of Radiology, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-8834, USA.
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Clifft JK, Coleman FA, Malone CB. Vascular disorder in a competitive cyclist: a case report. Physiother Theory Pract 2014; 30:517-20. [PMID: 24620853 DOI: 10.3109/09593985.2014.898351] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
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.
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Affiliation(s)
- Judy K Clifft
- Department of Physical Therapy, University of Tennessee Center for the Health Sciences , Memphis, TN , USA
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External Iliac Artery Fibrosis in Endurance Athletes Successfully Treated with Bypass Grafting. Ann Vasc Surg 2013; 27:1183.e1-4. [DOI: 10.1016/j.avsg.2013.01.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2012] [Revised: 01/03/2013] [Accepted: 01/04/2013] [Indexed: 11/23/2022]
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Hypothenar Hammer Syndrome From Ice Hockey Stick-Handling. Ann Vasc Surg 2013; 27:1183.e5-10. [DOI: 10.1016/j.avsg.2013.01.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Accepted: 01/28/2013] [Indexed: 11/22/2022]
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Impairment of 40-km time-trial performance but not peak power output with external iliac kinking: a case study in a world-class cyclist. Int J Sports Physiol Perform 2013; 9:720-2. [PMID: 24085374 DOI: 10.1123/ijspp.2013-0040b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Iliac blood-flow restrictions causing painful and "powerless" legs are often attributed to overtraining and may develop for some time before being correctly diagnosed. In the current study, differences between actual performance parameters and performance parameters predicted from the Lamberts and Lambert Submaximal Cycle Test (LSCT) were studied in a world-class cyclist with bilateral kinking of the external iliac artery before and after surgery. Two performance-testing sessions, including a peak-power-output (PPO) test and a 40-km time trial (TT) were conducted before surgery, while 1 testing session was conducted after the surgery. Actual vs LSCT-predicted performance parameters in the world-class cyclists were compared with 82 symptom-free trained to elite male cyclists. No differences were found between actual and LSCT-predicted PPO before and after surgical intervention. However, there were differences between actual and LSCT-predicted 40-km TT time in the tests performed before the surgery (2:51and 2:55 min:s, respectively). These differences were no longer apparent in the postsurgery 40-km TT (2 s). This finding suggests that iliac blood-flow restrictions seem to mainly impair endurance performance rather than peak cycling performance. A standard PPO test without brachial ankle blood-pressure measurements might not be able to reflect iliac blood-flow restrictions. Differences between actual and LSCT-predicted 40-km TT time may assist in earlier referral to a cardiovascular specialist and result in earlier detection of iliac blood-flow restrictions.
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Shalhub S, Zierler RE, Smith W, Olmsted K, Clowes AW. Vasospasm as a cause for claudication in athletes with external iliac artery endofibrosis. J Vasc Surg 2013; 58:105-11. [DOI: 10.1016/j.jvs.2012.12.060] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Revised: 12/17/2012] [Accepted: 12/19/2012] [Indexed: 10/27/2022]
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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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Rajasekaran S, Kvinlaug K, Finnoff JT. Exertional Leg Pain in the Athlete. PM R 2012; 4:985-1000. [DOI: 10.1016/j.pmrj.2012.10.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2012] [Revised: 10/03/2012] [Accepted: 10/05/2012] [Indexed: 01/27/2023]
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Lee SS, Rodriguez JA. External Iliac Artery Endofibrosis in Marathoner. Vasc Specialist Int 2012. [DOI: 10.5758/kjves.2012.28.2.96] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Sang Su Lee
- Department of Surgery, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Julio A. Rodriguez
- Department of Vascular Surgery, Arizona Heart Institute, Phoenix, USA
- Department of Vascular Surgery, Arizona Heart Hospital, Phoenix, USA
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Nakamura KM, Skeik N, Shepherd RF, Wennberg PW. External iliac vein thrombosis in an athletic cyclist with a history of external iliac artery endofibrosis and thrombosis. Vasc Endovascular Surg 2012; 45:761-4. [PMID: 22262119 DOI: 10.1177/1538574411418841] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
External iliac artery endofibrosis describes an intimal subendothelial fibrosis leading to wall thickening and stenosis that has been described in high-performance athletes. There are anatomical, mechanical, and probably metabolic factors that may contribute to this pathology. Ankle-brachial index (ABI) measurement with exercise testing, duplex ultrasound, computed tomography (CT) or magnetic resonance (MR) angiogram, and ultimately arteriography help to make the diagnosis. Management can be conservative, but most cases require surgical intervention. External iliac vein stenosis and thrombosis in cyclists has rarely been described in the literature. We report a case of extensive left lower limb deep venous thrombosis (DVT) including the external iliac vein diagnosed in a 57-year-old athletic cyclist with a history of external iliac artery thrombosis.
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Politano AD, Tracci MC, Gupta N, Hagspiel KD, Angle JF, Cherry KJ. Results of external iliac artery reconstruction in avid cyclists. J Vasc Surg 2012; 55:1338-44; discussion 1344-5. [DOI: 10.1016/j.jvs.2011.11.106] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2011] [Revised: 10/28/2011] [Accepted: 11/16/2011] [Indexed: 10/28/2022]
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Endofibrosis and Kinking of the Iliac Arteries in Athletes: A Systematic Review. Eur J Vasc Endovasc Surg 2012; 43:208-17. [DOI: 10.1016/j.ejvs.2011.11.019] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2011] [Accepted: 11/28/2011] [Indexed: 11/19/2022]
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Acute Thrombosis of External Iliac Artery Secondary to Endofibrosis. Ann Vasc Surg 2011; 25:698.e5-7. [DOI: 10.1016/j.avsg.2010.10.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2010] [Revised: 09/19/2010] [Accepted: 10/31/2010] [Indexed: 11/18/2022]
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Abstract
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.
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Affiliation(s)
- Alice A Perlowski
- Section of Vascular Medicine, Division of Cardiovascular Medicine, Massachusetts General Hospital, Boston, MA, USA
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Willson TD, Revesz E, Podbielski FJ, Blecha MJ. External iliac artery dissection secondary to endofibrosis in a cyclist. J Vasc Surg 2010; 52:219-21. [DOI: 10.1016/j.jvs.2010.02.259] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2010] [Revised: 02/19/2010] [Accepted: 02/21/2010] [Indexed: 12/01/2022]
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Abstract
Prolonged cycling has previously been associated with external iliac artery stenosis, termed "cyclists' iliac syndrome." However, no association between external iliac vein stenoses and cycling has been previously described. We describe a unique case of a 70-year-old cyclist presenting with an iliofemoral deep venous thrombosis owing to an external iliac vein stenosis. This is the first case of a potential association between cycling and iliac vein stenosis. Further study and follow-up will be required to assess whether angioplasty and stenting is the optimal method of therapy for iliac vein stenoses owing to cycling.
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Affiliation(s)
- Amr Salam
- College of Medical and dental Sciences, Univeristy of Birmingham, Birmingham, UK
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Abstract
OBJECTIVE Ankle-to-brachial index (ABI) can be easily performed by all physicians. The Ruffier-Dickson (RD) test is an easy procedure to attain moderate exercise at the bedside for physicians who do not have an ergometer. DESIGN Retrospective analysis. SETTING Tertiary care, institutional practice. PATIENTS Fifty-three asymptomatic athletes and 22 patients suffering from unilateral pain due to histologically proven exercise-induced arterial endofibrosis (EIAE). INTERVENTION Brachial and ankle systolic blood pressures were measured in the supine position on the suspected leg in EIAE or left leg in controls, at rest (rest) and at the first minute of the recovery from incremental maximal cycle ergometer exercise (maxCE) and Ruffier-Dickson (RD) exercise tests. MAIN OUTCOME MEASURES Comparison of ABI(rest), ABI(maxCE), and ABI(RD) in discriminating patients from normal subjects, using receiver operating characteristics (ROC) curves. RESULTS Area (+/-SE of area) of ROC curve was 0.76 +/- 0.06 for ABI(rest), 0.83 +/- 0.05 for ABI(RD) (nonsignificant from rest), and 0.99 +/- 0.01 for ABI(maxCE) (P < 0.01 from ABI(RD) and P < 0.001 from ABI(rest)). An ABI(maxCE) below 0.48 was 100% specific and 80% sensitive for EIAE. For the RD test, a 100% negative predictive value was only attained for postexercise ABI values higher than 0.92. CONCLUSION ABI after maximal cycle ergometer exercise is more accurate than ABI after an RD test to search for unilateral EIAE in athletes.
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