Endofibrosis and Kinking of the Iliac Arteries in Athletes: A Systematic Review

Abstract

Background: A policy of intra-operative transcranial Doppler (TCD) and completion angioscopy was previously associated with virtual abolition of intra-operative stroke (apparent upon recovery from anaesthesia) following carotid endarterectomy (CEA). The aims of this study were to determine whether the prevalence of technical error has diminished with experience and whether our monitoring/quality control policy was still associated with low rates of intra-operative stroke 20 years after its introduction. Methods: Retrospective review of four consecutive cohorts of 400 patients undergoing CEA between October 1995 and March 2010 (1600 CEAS in total). Results: One hundred four patients (7%) had thrombus removed following angioscopy and prior to flow restoration, while 31 (2.1%) underwent repair of a distal intimal flap. The prevalence of intimal flaps diminished from 4.9% in the first 400 patients to 0.8% in the last 400 patients (p ϭ 0.006). By contrast, the prevalence of retained thrombus did not decline with experience (8.5%, 3.7%, 10.3% and 5.4% for the four consecutive periods). Intra-operative TCD and completion angioscopy was, however, associated with extremely low rates of intra-operative stroke (0.25%, 0.25%, 0.5% and 0.25% during the four study periods). Conclusion: Most intra-operative strokes probably follow embolisation of thrombus following restoration of flow. This can be prevented by angioscopy which has the advantage of being performed prior to flow restoration. Increasing experience was associated with a decline in the detection of intimal flaps, but not in the prevalence of retained thrombus. Even the most experienced of surgeons can still be responsible for inadvertent technical error.

Management of a complicated triathlete’s bilateral iliac artery endofibrosis

“…1 In the early nineties a form of iliac artery disease affecting young and apparently healthy athletes was first described, and many years later it was defined as iliac artery endofibrosis (IAE). The low prevalence of the disease and the variety of clinical presentations make this disease very unknown and poorly studied, despite the improvement of image tests, and there are no standard treatment protocols.…”

“…2,3 Most are men, cyclists, but also described in many other sports, probably due to a combination of genetic factors and the greater number of men practising high-intensity sports. 1,3,4 From an anatomical point of view, it is caused by a thickening of the iliac artery intimae that causes hemodynamic stenosis. The reason of this local fibrosis is a repeated mechanical trauma on the artery and its secondary inflammatory response.…”

“…Both unilateral and bilateral cases have been reported, probably in relation with the type activity. 1,5 Histological studies of IAE show subintimal dense loose connective tissue deposits rich in elastin and actin-positive smooth muscle cells, making a clearly different disease when compared to atherosclerosis or other vascular diseases histology. Instead, atherosclerotic disease shows more densely packed collagen deposits; extensive calcification is present in almost all cases, while in endofibrotic disease this is uncommon.…”

“…It is empirically assumed that some patients may have a basally elongated iliac artery, being predisposed to early iliac endofibrosis when practising sports, as well as there could be patients with some uncommon metabolic abnormalities. 1,4,6,7 Iliac artery endofibrosis appears with clinical signs and symptoms of various characteristics and intensities, and this is why IAE is usually misdiagnosed. Symptoms can range from muscle claudication signs in the affected limb to subacute or acute limb ischemia due to complete obliteration of the iliac artery.…”

“…When there is only endofibrotic iliac stenosis, there is calf and proximal muscle pain in moderate-intense efforts appearing gradually, but there are no rest clinical signs and even peripheral pulses are present at rest. 1,3,8 Decrease of femoral systolic flow speed in duplex ultrasound evaluation is usually present, but when acute thrombosis or dissection of the iliac artery lead to complete arterial occlusion, ischemic signs are more clear, with absence of all pulses in the affected limb and short distance claudication or even paresthesia, pallor and rest pain. 1,4 Properly trained clinicians and vascular surgeons can easily perform a correct diagnosis with an appropriate anamnesis and physical examination.…”