Iliac artery endofibrosis

Iliac artery endofibrosis is a rare condition that affects young endurance athletes, characterized by a non-atherosclerotic stenosis of the iliac artery.

Epidemiology

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.

Clinical presentation

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 arterial stenosis usually occurs in the first 2-6 cm of the external iliac artery, however, the common iliac artery or the deep femoral artery can also be affected ².

The stenosis is progressive and can result in complete obstruction as a result of dissection or thrombosis ⁶.

Pathology

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.

Radiographic features

Ultrasound

The initial Doppler study is frequently normal except after high-intensity exercise, and it should not exclude the diagnosis.

CT/MRI

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. 

Angiography (DSA)

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.