Color Doppler Ultrasound Imaging in the Assessment of Iliac Endofibrosis

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.

The Investigation and Management of Iliac Artery Endofibrosis: Lessons Learned from a Case Series

“…Crosssectional imaging (e.g., computed tomography and magnetic resonance angiography) and invasive modalities such as angiogram appeared to offer little added value as the sensitivity of exercise ABPI and ultrasound Doppler became apparent. 3 In the present authors' opinion (as supported by recommendations from the INSITE group), 4 with the right technical expertise, ABPI and Doppler ultrasound are sufficient to diagnose iliac artery endofibrosis and crosssectional imaging should be reserved for instances of diagnostic uncertainty, where the extent of proximal disease cannot be visualised through ultrasound scanning, or for the planning of re-intervention.…”

“…Ultrasound findings suggestive of severe disease included a PSV of >350 cm/second, end diastolic velocity >150 cm/second, and monophasic post-exercise Doppler waveforms throughout the iliac arteries. 3 Later in the series, the CFA intima media thickness (IMT) was specifically looked for and reported if thickened in comparison with the contralateral limb.…”

“…For later cases, only an exercise ABPI and duplex ultrasound were felt necessary to confirm the diagnosis, reflecting changes in experience and the literature. 3,4 Femoral bruit 8 (14) Note. Data are n (%) unless otherwise indicated.…”

“…Complete occlusion (chronic) of the EIA was present in three cases. Vessel kinking (an inflection of two or more segments of an artery with an internal angle of 90 ) 3 and tortuosity (non-rectilinear stretch of an artery with an internal angle of 90 ) 3 was observed in a further five (one severe, three moderate, one mild kink; 9%) and three (5%) limbs, respectively. Both were infrequent and not considered a feature of endofibrosis unless associated with significant stenosis.…”

“…Increasing awareness of iliac artery endofibrosis over recent years has led to collaborative working, diagnostic algorithms, 2,3 and a consensus report from the "INternational Study group for Identification and Treatment of Endofibrosis (INSITE)". 4 A recent systematic review outlined findings from the handful of published series concerning iliac artery endofibrosis, 2 individually reporting between four and 25 cases.…”