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Iliac Artery Compression in Cyclists: Mechanisms, Diagnosis and Treatment

Open ArchivePublished:May 08, 2009DOI:https://doi.org/10.1016/j.ejvs.2009.03.024

      Abstract

      Objectives

      To review the mechanisms, diagnosis and treatment options for symptomatic iliac artery compression in cyclists.

      Methods

      Pubmed, Medline, Embase and Google were searched using combinations of the terms ‘iliac artery disease’, ‘iliac artery compression’, ‘iliac artery stenosis’, ‘cyclists’ and ‘athletes’.

      Results

      Tethering of the iliac artery by the psoas arterial branch and fibrous tissue, and muscular hypertrophy predispose the vessel to kinking and compression during cycling. Symptoms may only be present on maximal exercise in the cycling position. Provocative exercise tests using a cycling ergometer with ankle brachial pressure index measuring has a sensitivity of 85% to detect arterial insufficiency. Magnetic resonance imaging is increasingly being used as the investigation of choice to confirm the diagnosis, although digital subtraction angiography and colour duplex ultrasonography may also help. Conservative measures including adjustments to the cycling posture and bicycle setup should be recommended to all patients. The evidence for surgical and endovascular treatments is limited and the use of prosthetic graft should be avoided.

      Conclusions

      Iliac artery compression should be recognised as an important differential diagnosis in competitive cyclist presenting with lower limb symptoms. Although the optimal treatment strategy remains unclear, early diagnosis may reduce unnecessary investigations, and enable the cyclist to make appropriate adjustments and decisions in treatment management.

      Keywords

      Introduction

      Iliac artery compression in athletes was first described in 1984
      • Walder J.
      • Mosimann F.
      • Van Melle G.
      • Mosimann R.
      A propos de l'endofibrose iliaque chez deux coureurs cyclistes.
      and the majority of patients are competitive cyclists (90%),
      • Chevalier J.M.
      Pathologie vasculaire du cyclistes.
      although similar disease in runners,
      • Chevalier J.M.
      Pathologie vasculaire du cyclistes.
      • Gallegos C.R.
      • Studley J.G.
      • Hamer D.B.
      External iliac artery occlusion – another complication of long distance running?.
      • Monti M.
      • Jaeger M.
      • Guisan Y.
      • Payot M.
      • Mazzoni S.
      cross-country skiers,
      • Chevalier J.M.
      Pathologie vasculaire du cyclistes.
      rugby players,
      • Bray A.E.
      • Lewis W.A.
      Intermittent claudication in a professional rugby player.
      footballers
      • Masmoudi S.
      • Frikha I.
      • Hadjkacem A.
      • Yangui M.
      • Mnif J.
      • Elleuch H.
      • et al.
      and body builders
      • Khaira H.S.
      • Awad R.W.
      • Aluwihare N.
      • Shearman C.P.
      External iliac artery stenosis in a young body builder.
      have also been reported. As competitive cyclists usually have a high level of fitness, diseases of musculoskeletal, neurological or general deterioration in performance are usually considered before arterial insufficiency.
      • Ehsan O.
      • Darwish A.
      • Edmundson C.
      • Mills V.
      • Al-Khaffaf H.
      Non-traumatic lower limb vascular complications in endurance athletes. Review of literature.
      • Schep G.
      • Bender M.H.
      • van de Tempel G.
      • Wijn P.F.
      • de Vries W.R.
      • Eikelboom B.C.
      Detection and treatment of claudication due to functional iliac obstruction in top endurance athletes: a prospective study.
      Consequently, the mean delay to diagnosis of iliac artery compression/endofibrosis in competitive cyclists is 2 years
      • Ford S.J.
      • Rehman A.
      • Bradbury A.W.
      External iliac endofibrosis in endurance athletes: a novel case in an endurance runner and a review of the literature.
      • Kral C.A.
      • Han D.C.
      • Edwards W.D.
      • Spittell P.C.
      • Tazelaar H.D.
      • Cherry Jr., K.J.
      Obstructive external iliac arteriopathy in avid bicyclists: new and variable histopathologic features in four women.
      from initial presentation.
      • Alimi Y.S.
      • Accrocca F.
      • Barthelemy P.
      • Hartung O.
      • Dubuc M.
      • Boufi M.
      Comparison between duplex scanning and angiographic findings in the evaluation of functional iliac obstruction in top endurance athletes.
      • Taylor A.J.
      • George K.P.
      Ankle to brachial pressure index in normal subjects and trained cyclists with exercise-induced leg pain.
      • Schep G.
      • Bender M.H.
      • Kaandorp D.
      • Hammacher E.
      • de Vries W.R.
      Flow limitations in the iliac arteries in endurance athletes. Current knowledge and directions for the future.
      • Sise M.J.
      • Shackford S.R.
      • Rowley W.R.
      • Pistone F.J.
      Claudication in young adults: a frequently delayed diagnosis.
      • Taylor A.J.
      • Tennant W.G.
      • Batt M.E.
      • Wallace W.A.
      Traumatic occlusion of the external iliac artery in a racing cyclist: a cause of ill defined leg pain.
      • Abraham P.
      • Chevalier J.M.
      • Saumet J.L.
      External iliac artery endofibrosis: a 40-year course.
      • Abraham P.
      • Saumet J.L.
      • Chevalier J.M.
      External iliac artery endofibrosis in athletes.
      It is likely that many patients have been forced to give up competitive cycling, without a diagnosis.
      • Taylor A.J.
      • George K.P.
      Ankle to brachial pressure index in normal subjects and trained cyclists with exercise-induced leg pain.
      • Sise M.J.
      • Shackford S.R.
      • Rowley W.R.
      • Pistone F.J.
      Claudication in young adults: a frequently delayed diagnosis.
      • Taylor A.J.
      • Tennant W.G.
      • Batt M.E.
      • Wallace W.A.
      Traumatic occlusion of the external iliac artery in a racing cyclist: a cause of ill defined leg pain.
      • Abraham P.
      • Chevalier J.M.
      • Saumet J.L.
      External iliac artery endofibrosis: a 40-year course.
      • Abraham P.
      • Saumet J.L.
      • Chevalier J.M.
      External iliac artery endofibrosis in athletes.
      • Chevalier J.M.
      • Enon B.
      • Walder J.
      • Barral X.
      • Pillet J.
      • Megret A.
      • et al.
      L'endofibrose iliaque externe du cycliste de competition: une pathologie arterielle meconnue.

      Methods

      We searched Pubmed, Medline, Embase and Google™ using combinations of the search terms ‘iliac artery disease’ or ‘iliac artery compression’ or ‘iliac artery stenosis’ and ‘cyclists’ or ‘athletes’. To increase our search results, we then searched the Google™ using the phrases “iliac artery disease” cyclists, “iliac artery disease” athletes, “iliac artery compression” cyclists, “iliac artery compression” athletes, “iliac artery stenosis” cyclists, and “iliac artery stenosis” athletes. Articles and webpages that had no mention of iliac artery compression syndrome in athletes were excluded.

      Results

      A total of 24 articles were found using Pubmed, Medline and Embase. All of them were reviewed. A further search in Google™ identified 99 webpages, of which 65 mentioned iliac artery compression syndrome in athletes and assessed.

      How Common is Iliac Artery Compression in Cyclists?

      Although the true prevalence of iliac artery compression secondary to cycling is unknown, vascular insufficiency may account for up to 10–20% of leg symptoms in top-level competitive cyclists.
      • Moen E.
      Copore sano. An emerging occupational hazard.
      • Schep G.
      • Kaandorp D.W.
      • Bender M.H.
      • Van Engeland S.
      • Weerdenburg H.
      • Titulaer B.M.
      • et al.
      Excessive length of iliac arteries in athletes with flow limitations measured by magnetic resonance angiography.
      • Schep G.
      • Kaandorp D.W.
      • Bender M.H.
      • Weerdenburg H.
      • van Engeland S.
      • Wijn P.F.
      Magnetic resonance angiography used to detect kinking in the iliac arteries in endurance athletes with claudication.
      There were more cases reported in men than women.
      • Kral C.A.
      • Han D.C.
      • Edwards W.D.
      • Spittell P.C.
      • Tazelaar H.D.
      • Cherry Jr., K.J.
      Obstructive external iliac arteriopathy in avid bicyclists: new and variable histopathologic features in four women.
      Patients usually present at a much younger age (average of 25 years; range 16–42 years)
      • Kral C.A.
      • Han D.C.
      • Edwards W.D.
      • Spittell P.C.
      • Tazelaar H.D.
      • Cherry Jr., K.J.
      Obstructive external iliac arteriopathy in avid bicyclists: new and variable histopathologic features in four women.
      than those with atherosclerosis. It has been reported that of those who developed the problem, 15% were professional, 48% top amateur, and 28% recreational cyclists.
      • Chevalier J.M.
      Pathologie vasculaire du cyclistes.
      • Ford S.J.
      • Rehman A.
      • Bradbury A.W.
      External iliac endofibrosis in endurance athletes: a novel case in an endurance runner and a review of the literature.
      The reported level of cycling is 8000–35,000 km per year
      • Kral C.A.
      • Han D.C.
      • Edwards W.D.
      • Spittell P.C.
      • Tazelaar H.D.
      • Cherry Jr., K.J.
      Obstructive external iliac arteriopathy in avid bicyclists: new and variable histopathologic features in four women.
      • Schep G.
      • Bender M.H.
      • Kaandorp D.
      • Hammacher E.
      • de Vries W.R.
      Flow limitations in the iliac arteries in endurance athletes. Current knowledge and directions for the future.
      or about 150,000 km in a lifetime.
      • Ford S.J.
      • Rehman A.
      • Bradbury A.W.
      External iliac endofibrosis in endurance athletes: a novel case in an endurance runner and a review of the literature.
      • O'Ceallaigh P.
      • Burns P.
      • McLaughlin R.
      • Leader M.
      • Bouchier-Hayes D.
      Complete external iliac artery occlusion in a 34-year-old cyclist.
      • Blanes-Mompó J.I.
      • Crespo-Moreno I.
      • Gómez-Palonés F.
      • Martínez-Meléndez S.
      • Martínez-Perelló I.
      • Ortiz-Monzón E.
      • et al.
      Claudicación intermitente en el adulto joven: arteriopatía no arteriosclerótica.
      The external iliac artery is most commonly involved (90%), although multiple segments of the artery may be diseased in about 10% of cases.
      • Ford S.J.
      • Rehman A.
      • Bradbury A.W.
      External iliac endofibrosis in endurance athletes: a novel case in an endurance runner and a review of the literature.
      The condition is bilateral in around 15%,
      • Ford S.J.
      • Rehman A.
      • Bradbury A.W.
      External iliac endofibrosis in endurance athletes: a novel case in an endurance runner and a review of the literature.
      but there seems to be a left iliac artery predominance.
      • Chevalier J.M.
      Pathologie vasculaire du cyclistes.
      • Ford S.J.
      • Rehman A.
      • Bradbury A.W.
      External iliac endofibrosis in endurance athletes: a novel case in an endurance runner and a review of the literature.
      • Schep G.
      • Bender M.H.
      • Kaandorp D.
      • Hammacher E.
      • de Vries W.R.
      Flow limitations in the iliac arteries in endurance athletes. Current knowledge and directions for the future.
      • Abraham P.
      • Chevalier J.M.
      • Saumet J.L.
      External iliac artery endofibrosis: a 40-year course.
      • Abraham P.
      • Saumet J.L.
      • Chevalier J.M.
      External iliac artery endofibrosis in athletes.
      • Abraham P.
      • Bickert S.
      • Vielle B.
      • Chevalier J.M.
      • Saumet J.L.
      Pressure measurements at rest and after heavy exercise to detect moderate arterial lesions in athletes.
      Rarely, patients may also present with associated dissection of the iliac artery.
      • Teh L.G.
      • Sieunarine K.
      • Van Schie G.
      • Vasudevan T.
      Spontaneous common iliac artery dissection after exercise.

      What Are the Mechanisms Contributing to Iliac Artery Compression in Cyclists?

      Numerous anatomical, mechanical and postural factors are likely to contribute to the development of iliac artery disease (Figure 1, Figure 2). Recurrent exposure to these factors (from repetitive competitive cycling), inflammatory and remodelling processes in the artery are thought to result in a stenotic intravascular lesion, known as endofibrosis.
      • Chevalier J.M.
      • Enon B.
      • Walder J.
      • Barral X.
      • Pillet J.
      • Megret A.
      • et al.
      L'endofibrose iliaque externe du cycliste de competition: une pathologie arterielle meconnue.
      • Rousselet M.C.
      • Saint-Andre J.P.
      • L'Hoste P.
      • Enon B.
      • Megret A.
      • Chevalier J.M.
      Stenotic intimal thickening of the external iliac artery in competition cyclists.
      Specific contributory factors may be:
      Figure thumbnail gr1
      Figure 1Anatomical predisposing factors that may contribute to iliac artery compression syndrome during cycling.
      Figure thumbnail gr2
      Figure 2Iliac artery during upright and hip hyperflexion hip. Dark arrow demonstrated acute angle of the iliac artery during hip hyperflexion when cycling.

      Posture

      The aerodynamic posture that involves hip hyperflexion is characteristic in competitive cyclists
      • Ford S.J.
      • Rehman A.
      • Bradbury A.W.
      External iliac endofibrosis in endurance athletes: a novel case in an endurance runner and a review of the literature.
      and it has been estimated that this movement may be repeated up to 8 million times a year.
      • Schep G.
      • Bender M.H.
      • Kaandorp D.
      • Hammacher E.
      • de Vries W.R.
      Flow limitations in the iliac arteries in endurance athletes. Current knowledge and directions for the future.
      Repetitive hyperflexion of the hip causes bending and stretching of the external iliac artery (Fig. 2), which may damage the arterial wall, most commonly seen at its greater curvature.
      • Kral C.A.
      • Han D.C.
      • Edwards W.D.
      • Spittell P.C.
      • Tazelaar H.D.
      • Cherry Jr., K.J.
      Obstructive external iliac arteriopathy in avid bicyclists: new and variable histopathologic features in four women.
      • Chevalier J.M.
      • Enon B.
      • Walder J.
      • Barral X.
      • Pillet J.
      • Megret A.
      • et al.
      L'endofibrose iliaque externe du cycliste de competition: une pathologie arterielle meconnue.
      • Rousselet M.C.
      • Saint-Andre J.P.
      • L'Hoste P.
      • Enon B.
      • Megret A.
      • Chevalier J.M.
      Stenotic intimal thickening of the external iliac artery in competition cyclists.

      Anatomical predisposition and kinking of artery

      The longitudinal elasticity and excess length of the iliac artery are usually able to compensate for stretching and movement during normal activity.
      • Schep G.
      • Kaandorp D.W.
      • Bender M.H.
      • Van Engeland S.
      • Weerdenburg H.
      • Titulaer B.M.
      • et al.
      Excessive length of iliac arteries in athletes with flow limitations measured by magnetic resonance angiography.
      However, fixation of the iliac artery may tether the vessel, causing kinking of the vessel during hip flexion.
      • Schep G.
      • Bender M.H.
      • Kaandorp D.
      • Hammacher E.
      • de Vries W.R.
      Flow limitations in the iliac arteries in endurance athletes. Current knowledge and directions for the future.
      • Schep G.
      • Kaandorp D.W.
      • Bender M.H.
      • Van Engeland S.
      • Weerdenburg H.
      • Titulaer B.M.
      • et al.
      Excessive length of iliac arteries in athletes with flow limitations measured by magnetic resonance angiography.
      Such kinking has been observed in 70% of the cyclists operated for arterial insufficiency.
      • Schep G.
      • Bender M.H.
      • van de Tempel G.
      • Wijn P.F.
      • de Vries W.R.
      • Eikelboom B.C.
      Detection and treatment of claudication due to functional iliac obstruction in top endurance athletes: a prospective study.
      Most commonly such tethering is caused by a psoas side branch of the iliac artery (52–60%)
      • Chevalier J.M.
      Pathologie vasculaire du cyclistes.
      • Schep G.
      • Bender M.H.
      • van de Tempel G.
      • Wijn P.F.
      • de Vries W.R.
      • Eikelboom B.C.
      Detection and treatment of claudication due to functional iliac obstruction in top endurance athletes: a prospective study.
      and fibrous fixation of the iliac bifurcation (78%),
      • Schep G.
      • Bender M.H.
      • van de Tempel G.
      • Wijn P.F.
      • de Vries W.R.
      • Eikelboom B.C.
      Detection and treatment of claudication due to functional iliac obstruction in top endurance athletes: a prospective study.
      although about 9% were of unknown origin.
      • Schep G.
      • Bender M.H.
      • van de Tempel G.
      • Wijn P.F.
      • de Vries W.R.
      • Eikelboom B.C.
      Detection and treatment of claudication due to functional iliac obstruction in top endurance athletes: a prospective study.
      Tethering may also occur at the circumflex iliac, epigastric and pudendal branches.
      • Ford S.J.
      • Rehman A.
      • Bradbury A.W.
      External iliac endofibrosis in endurance athletes: a novel case in an endurance runner and a review of the literature.
      • Lopez J.F.
      • Magne J.L.
      • Champetier J.
      The femoral artery and flexion of the hip joint.
      Excessive vessel length and tortuosity may also predispose the artery to kinking during hip hyperflexion.
      • Chevalier J.M.
      Pathologie vasculaire du cyclistes.
      • Schep G.
      • Bender M.H.
      • Kaandorp D.
      • Hammacher E.
      • de Vries W.R.
      Flow limitations in the iliac arteries in endurance athletes. Current knowledge and directions for the future.
      • Schep G.
      • Kaandorp D.W.
      • Bender M.H.
      • Van Engeland S.
      • Weerdenburg H.
      • Titulaer B.M.
      • et al.
      Excessive length of iliac arteries in athletes with flow limitations measured by magnetic resonance angiography.
      Kinking of the artery alone may cause flow limitation in cyclists,
      • Schep G.
      • Kaandorp D.W.
      • Bender M.H.
      • Weerdenburg H.
      • van Engeland S.
      • Wijn P.F.
      Magnetic resonance angiography used to detect kinking in the iliac arteries in endurance athletes with claudication.
      but secondary endofibrotic damage may further exacerbate symptoms.
      • Chevalier J.M.
      • Enon B.
      • Walder J.
      • Barral X.
      • Pillet J.
      • Megret A.
      • et al.
      L'endofibrose iliaque externe du cycliste de competition: une pathologie arterielle meconnue.
      In one study that used colour Doppler to assess 50 endurance athletes (46 cyclists) with 54 symptomatic legs and 16 asymptomatic cyclists (28 reference legs) as controls, significantly more symptomatic legs were found to have kinks and/or intravascular lesions in the external iliac artery than the asymptomatic legs when the hips were flexed.
      • Schep G.
      • Bender M.H.
      • Schmikli S.L.
      • Wijn P.F.
      Color Doppler used to detect kinking and intravascular lesions in the iliac arteries in endurance athletes with claudication.
      Furthermore, the presence of kinks and/or intravascular lesions in the external iliac artery seemed to be associated with higher peak systolic velocities.
      • Schep G.
      • Bender M.H.
      • Schmikli S.L.
      • Wijn P.F.
      Color Doppler used to detect kinking and intravascular lesions in the iliac arteries in endurance athletes with claudication.

      Muscular hypertrophy

      Competitive cyclists develop muscular hypertrophy from intensive training. Hypertrophied hip flexors (especially the psoas muscles) and abdominal muscles (such as external oblique) may compress the iliac artery.
      • Ford S.J.
      • Rehman A.
      • Bradbury A.W.
      External iliac endofibrosis in endurance athletes: a novel case in an endurance runner and a review of the literature.
      • Shankar V.A.
      • Roskell D.
      • Darby C.
      Iliac artery syndrome: successful outcome after endarterectomy and vein patch angioplasty.
      • Carmo G.
      • Rosa A.
      • Ministro A.
      • Cunha E.S.D.
      • Pestana C.
      • Scheerder M.J.
      • Schutte P.R.
      • Schnater J.M.
      • Scavee V.
      • Stainier L.
      • Deltombe T.
      • Theys S.
      • Delos M.
      • Trigaux J.P.
      • et al.
      External iliac artery endofibrosis: a new possible predisposing factor.
      Muscular hypertrophy may also cause chronic stretching and lengthening of the iliac artery, hence predisposing it to kinking.
      • O'Ceallaigh P.
      • Burns P.
      • McLaughlin R.
      • Leader M.
      • Bouchier-Hayes D.
      Complete external iliac artery occlusion in a 34-year-old cyclist.
      • Scheerder M.J.
      • Schutte P.R.
      • Schnater J.M.

      Endofibrosis

      Endofibrosis refers to a stenotic endovascular lesion as a result of mechanical stress.
      • Schep G.
      • Bender M.H.
      • van de Tempel G.
      • Wijn P.F.
      • de Vries W.R.
      • Eikelboom B.C.
      Detection and treatment of claudication due to functional iliac obstruction in top endurance athletes: a prospective study.
      • Rousselet M.C.
      • Saint-Andre J.P.
      • L'Hoste P.
      • Enon B.
      • Megret A.
      • Chevalier J.M.
      Stenotic intimal thickening of the external iliac artery in competition cyclists.
      It usually causes an isolated narrowing of 10–20% in the iliac artery.
      • Le Faucheur A.
      • Noury-Desvaux B.
      • Jaquinandi V.
      • Louis Saumet J.
      • Abraham P.
      Simultaneous arterial pressure recordings improve the detection of endofibrosis.
      Histologically, endofibrosis is a different entity compared to atherosclerosis and fibromuscular dysplasia.
      • Ford S.J.
      • Rehman A.
      • Bradbury A.W.
      External iliac endofibrosis in endurance athletes: a novel case in an endurance runner and a review of the literature.
      • Giannoukas A.D.
      • Berczi V.
      • Anoop U.
      • Cleveland T.J.
      • Beard J.D.
      • Gaines P.A.
      Endofibrosis of iliac arteries in high-performance athletes: diagnostic approach and minimally invasive endovascular treatment.
      • Vink A.
      • Bender M.H.
      • Schep G.
      • van Wichen D.F.
      • de Weger R.A.
      • Pasterkamp G.
      • et al.
      Histopathological comparison between endofibrosis of the high-performance cyclist and atherosclerosis in the external iliac artery.
      It is characterised by intimal hyperplasia set in a moderately loose cellular connective tissue with variable amounts of elastin and collagen.
      • Ford S.J.
      • Rehman A.
      • Bradbury A.W.
      External iliac endofibrosis in endurance athletes: a novel case in an endurance runner and a review of the literature.
      • O'Ceallaigh P.
      • Burns P.
      • McLaughlin R.
      • Leader M.
      • Bouchier-Hayes D.
      Complete external iliac artery occlusion in a 34-year-old cyclist.
      • Giannoukas A.D.
      • Berczi V.
      • Anoop U.
      • Cleveland T.J.
      • Beard J.D.
      • Gaines P.A.
      Endofibrosis of iliac arteries in high-performance athletes: diagnostic approach and minimally invasive endovascular treatment.
      • Vink A.
      • Bender M.H.
      • Schep G.
      • van Wichen D.F.
      • de Weger R.A.
      • Pasterkamp G.
      • et al.
      Histopathological comparison between endofibrosis of the high-performance cyclist and atherosclerosis in the external iliac artery.
      • Wright I.A.
      • Pugh N.D.
      • Goodfellow J.
      • Wood A.M.
      • Lane I.F.
      • Fraser A.G.
      Dynamic obstruction of the external iliac artery in endurance athletes and its relationship to endothelial function: the case of a long distance runner.
      • Paraf F.
      • Petit B.
      • Roux J.
      • Bertin F.
      • Laskar M.
      • Labrousse F.
      Immunostaining demonstrated smooth muscle cells proliferation in the intima and adventitia.
      • Kral C.A.
      • Han D.C.
      • Edwards W.D.
      • Spittell P.C.
      • Tazelaar H.D.
      • Cherry Jr., K.J.
      Obstructive external iliac arteriopathy in avid bicyclists: new and variable histopathologic features in four women.
      • Rousselet M.C.
      • Saint-Andre J.P.
      • L'Hoste P.
      • Enon B.
      • Megret A.
      • Chevalier J.M.
      Stenotic intimal thickening of the external iliac artery in competition cyclists.
      One study reported intimal fibroplasia occurs in 80% of the cases, while medial hypertrophy 60%, adventitial hyperplasia 80% and iliac artery thrombosis 40%.
      • Kral C.A.
      • Han D.C.
      • Edwards W.D.
      • Spittell P.C.
      • Tazelaar H.D.
      • Cherry Jr., K.J.
      Obstructive external iliac arteriopathy in avid bicyclists: new and variable histopathologic features in four women.
      Other rarer morphological appearances which have been described include medial calcification and fibrosis.
      • Kral C.A.
      • Han D.C.
      • Edwards W.D.
      • Spittell P.C.
      • Tazelaar H.D.
      • Cherry Jr., K.J.
      Obstructive external iliac arteriopathy in avid bicyclists: new and variable histopathologic features in four women.
      Affected artery segments were free from atherosclerosis.
      • Teh L.G.
      • Sieunarine K.
      • Van Schie G.
      • Vasudevan T.
      Spontaneous common iliac artery dissection after exercise.
      High blood flow through the iliac artery generated from increased cardiac output and systolic blood pressure during competitive cycling has been proposed as a potential contributory mechanism to vascular wall injury leading to endofibrosis.
      • Ford S.J.
      • Rehman A.
      • Bradbury A.W.
      External iliac endofibrosis in endurance athletes: a novel case in an endurance runner and a review of the literature.
      • Kral C.A.
      • Han D.C.
      • Edwards W.D.
      • Spittell P.C.
      • Tazelaar H.D.
      • Cherry Jr., K.J.
      Obstructive external iliac arteriopathy in avid bicyclists: new and variable histopathologic features in four women.
      • Taylor A.J.
      • Tennant W.G.
      • Batt M.E.
      • Wallace W.A.
      Traumatic occlusion of the external iliac artery in a racing cyclist: a cause of ill defined leg pain.
      However, there is little evidence to support this.

      How Does Iliac Artery Compression in Cyclists Present Clinically?

      Cyclists with iliac artery compression may be asymptomatic at rest or during sub-maximal exercise. Features of arterial insufficiency may only be present at maximum exertion and/or during hip hyperflexion. Symptoms may include vague lower limb pain, cramp, numbness, weakness, claudication, unexplained deterioration of cycling performance and swelling.
      • Ford S.J.
      • Rehman A.
      • Bradbury A.W.
      External iliac endofibrosis in endurance athletes: a novel case in an endurance runner and a review of the literature.
      • Kral C.A.
      • Han D.C.
      • Edwards W.D.
      • Spittell P.C.
      • Tazelaar H.D.
      • Cherry Jr., K.J.
      Obstructive external iliac arteriopathy in avid bicyclists: new and variable histopathologic features in four women.
      • Taylor A.J.
      • George K.P.
      Ankle to brachial pressure index in normal subjects and trained cyclists with exercise-induced leg pain.
      • Del Gallo G.
      • Plissonnier D.
      • Planet M.
      • Peillon C.
      • Testart J.
      • Watelet J.
      The lower limb pain often affects the thigh rather than the buttock and calf.
      • Taylor A.J.
      • Tennant W.G.
      • Batt M.E.
      • Wallace W.A.
      Traumatic occlusion of the external iliac artery in a racing cyclist: a cause of ill defined leg pain.
      • Chevalier J.M.
      • Beck F.
      • Megret A.
      Endofibrose arterielle du sportif.
      • Feugier P.
      • Chevalier J.M.
      Endofibrosis of the iliac arteries: an underestimated problem.
      On clinical examination, lower limb pulses are usually present with normal capillary refilling time. A bruit in the iliac fossa may be auscultated (44%).
      • Ford S.J.
      • Rehman A.
      • Bradbury A.W.
      External iliac endofibrosis in endurance athletes: a novel case in an endurance runner and a review of the literature.
      • Kral C.A.
      • Han D.C.
      • Edwards W.D.
      • Spittell P.C.
      • Tazelaar H.D.
      • Cherry Jr., K.J.
      Obstructive external iliac arteriopathy in avid bicyclists: new and variable histopathologic features in four women.
      • Abraham P.
      • Bickert S.
      • Vielle B.
      • Chevalier J.M.
      • Saumet J.L.
      Pressure measurements at rest and after heavy exercise to detect moderate arterial lesions in athletes.

      What Investigations May Help in the Diagnosis of Iliac Artery Compression in Cyclists?

      A combination of provocative exercise tests and vascular imaging, along with a high index of clinical suspicion, is usually required. Conventional investigation techniques may need to be modified to mimic the posture of competitive cycling and/or to produce maximum exertion.

      Provocative exercise test and ankle brachial pressure index (ABPI)

      The resting and conventional post-exercise ABPI of these patients are usually normal.
      • Taylor A.J.
      • George K.P.
      Ankle to brachial pressure index in normal subjects and trained cyclists with exercise-induced leg pain.
      • Arko F.R.
      • Harris E.J.
      • Zarins C.K.
      • Olcott Ct
      Vascular complications in high-performance athletes.
      Therefore, specific cycle-ergometer-based protocols rather than standard treadmill exercises are more appropriate.
      • Ford S.J.
      • Rehman A.
      • Bradbury A.W.
      External iliac endofibrosis in endurance athletes: a novel case in an endurance runner and a review of the literature.
      • Taylor A.J.
      • George K.P.
      Ankle to brachial pressure index in normal subjects and trained cyclists with exercise-induced leg pain.
      • Giannoukas A.D.
      • Berczi V.
      • Anoop U.
      • Cleveland T.J.
      • Beard J.D.
      • Gaines P.A.
      Endofibrosis of iliac arteries in high-performance athletes: diagnostic approach and minimally invasive endovascular treatment.
      It has been reported that the ABPI of pre- and post-maximal exercise on an ergometer would detect abnormalities in the arterial flow in about 85% of the cases.
      • Abraham P.
      • Saumet J.L.
      • Chevalier J.M.
      External iliac artery endofibrosis in athletes.
      In the first minute post-maximal exercise, ABPI drops of 0.50 (sensitivity of 80–85%; specificity not reported)
      • Chevalier J.M.
      • Beck F.
      • Megret A.
      Endofibrose arterielle du sportif.
      • Abraham P.
      • Chevalier J.M.
      • Leftheriotis G.
      • Saumet J.L.
      Lower extremity arterial disease in sports.
      and 0.66 (sensitivity of 90% and specificity of 87%)
      • Abraham P.
      • Bickert S.
      • Vielle B.
      • Chevalier J.M.
      • Saumet J.L.
      Pressure measurements at rest and after heavy exercise to detect moderate arterial lesions in athletes.
      have been suggested. Other measurement and technical modifications such as ABPI to heart ratio
      • Abraham P.
      • Bickert S.
      • Vielle B.
      • Chevalier J.M.
      • Saumet J.L.
      Pressure measurements at rest and after heavy exercise to detect moderate arterial lesions in athletes.
      and simultaneous automated pressure measurements of all the limbs
      • Le Faucheur A.
      • Noury-Desvaux B.
      • Jaquinandi V.
      • Louis Saumet J.
      • Abraham P.
      Simultaneous arterial pressure recordings improve the detection of endofibrosis.
      have also been studied, although the validity of such methods is yet to be proven.

      Imaging

      Imaging for iliac artery disease is challenging as intravascular lesions in cyclists are often much smaller than those of atherosclerosis and may be dismissed as insignificant.
      • Schep G.
      • Kaandorp D.W.
      • Bender M.H.
      • Weerdenburg H.
      • van Engeland S.
      • Wijn P.F.
      Magnetic resonance angiography used to detect kinking in the iliac arteries in endurance athletes with claudication.
      Many conventional imaging tools only produce two-dimensional pictures. Endofibrotic lesions may not lie in the visualised plane and could be overlooked as they are often situated eccentrically in the vessel.
      • Chevalier J.M.
      Pathologie vasculaire du cyclistes.
      • Schep G.
      • Bender M.H.
      • Kaandorp D.
      • Hammacher E.
      • de Vries W.R.
      Flow limitations in the iliac arteries in endurance athletes. Current knowledge and directions for the future.
      • Abraham P.
      • Leftheriotis G.
      • Bourre Y.
      • Chevalier J.M.
      • Saumet J.L.
      Echography of external iliac artery endofibrosis in cyclists.
      During conventional imaging, the posture of the patient is often very different to competitive cycling. Therefore, some abnormalities including kinking or compression of the iliac artery that may only occur during hip hyperflexion may be missed.
      • Ford S.J.
      • Rehman A.
      • Bradbury A.W.
      External iliac endofibrosis in endurance athletes: a novel case in an endurance runner and a review of the literature.
      • Schep G.
      • Bender M.H.
      • Kaandorp D.
      • Hammacher E.
      • de Vries W.R.
      Flow limitations in the iliac arteries in endurance athletes. Current knowledge and directions for the future.
      • Schep G.
      • Bender M.H.
      • Schmikli S.L.
      • Wijn P.F.
      Color Doppler used to detect kinking and intravascular lesions in the iliac arteries in endurance athletes with claudication.

      Digital subtraction angiography (DSA)

      During angiography, an iliac artery lesion may appear as a beaded or smooth stenotic lesion usually starting just distal to the common iliac bifurcation and extending for about 5–6 cm down the external iliac artery.
      • Schep G.
      • Bender M.H.
      • Kaandorp D.
      • Hammacher E.
      • de Vries W.R.
      Flow limitations in the iliac arteries in endurance athletes. Current knowledge and directions for the future.
      • Wijesinghe L.D.
      • Coughlin P.A.
      • Robertson I.
      • Kessel D.
      • Kent P.J.
      • Kester R.C.
      Cyclist's iliac syndrome: temporary relief by balloon angioplasty.
      Calcification is uncommon. Direct comparison with the contralateral limb is essential as stenotic lesions may be subtle.
      • Ford S.J.
      • Rehman A.
      • Bradbury A.W.
      External iliac endofibrosis in endurance athletes: a novel case in an endurance runner and a review of the literature.
      During angiography the intravascular pressure gradient can also be measured. At rest, this is likely to be normal but a gradient may become detectable across the affected segment after pharmacologically induced distal vasodilatation such as using papaverine.
      • Giannoukas A.D.
      • Berczi V.
      • Anoop U.
      • Cleveland T.J.
      • Beard J.D.
      • Gaines P.A.
      Endofibrosis of iliac arteries in high-performance athletes: diagnostic approach and minimally invasive endovascular treatment.
      • Wijesinghe L.D.
      • Coughlin P.A.
      • Robertson I.
      • Kessel D.
      • Kent P.J.
      • Kester R.C.
      Cyclist's iliac syndrome: temporary relief by balloon angioplasty.
      One study of 13 patients of highly trained athletes (10 cyclists) reported that DSA (with hip flexion and extension) had sensitivities of 53.8%, 57.1% and 57.1% and specificities of 0%, 100%, and 100% for the detection of external iliac artery stenosis, the presence of a psoas artery branch, and long external iliac artery, respectively.
      • Alimi Y.S.
      • Accrocca F.
      • Barthelemy P.
      • Hartung O.
      • Dubuc M.
      • Boufi M.
      Comparison between duplex scanning and angiographic findings in the evaluation of functional iliac obstruction in top endurance athletes.
      In this study the sensitivity of DSA in diagnosing common iliac artery stenosis was only 12.5% (specificity of 100%).
      • Alimi Y.S.
      • Accrocca F.
      • Barthelemy P.
      • Hartung O.
      • Dubuc M.
      • Boufi M.
      Comparison between duplex scanning and angiographic findings in the evaluation of functional iliac obstruction in top endurance athletes.
      In another study, when all the examinations were performed in a ‘racing’ hyperflexed posture, DSA demonstrated abnormalities in 100% of the cases.
      • Kral C.A.
      • Han D.C.
      • Edwards W.D.
      • Spittell P.C.
      • Tazelaar H.D.
      • Cherry Jr., K.J.
      Obstructive external iliac arteriopathy in avid bicyclists: new and variable histopathologic features in four women.

      Magnetic resonance angiography (MRA)

      MRA is increasingly being used as the investigation of choice to diagnose iliac artery compression following a positive provocative test. MRA may have a higher sensitivity than DSA.
      • Schep G.
      • Bender M.H.
      • van de Tempel G.
      • Wijn P.F.
      • de Vries W.R.
      • Eikelboom B.C.
      Detection and treatment of claudication due to functional iliac obstruction in top endurance athletes: a prospective study.
      • Ford S.J.
      • Rehman A.
      • Bradbury A.W.
      External iliac endofibrosis in endurance athletes: a novel case in an endurance runner and a review of the literature.
      There are numerous potential advantages of MRA including:
      • Non-invasive and able to reconstruct three-dimensional images
        • Ford S.J.
        • Rehman A.
        • Bradbury A.W.
        External iliac endofibrosis in endurance athletes: a novel case in an endurance runner and a review of the literature.
        • Giannoukas A.D.
        • Berczi V.
        • Anoop U.
        • Cleveland T.J.
        • Beard J.D.
        • Gaines P.A.
        Endofibrosis of iliac arteries in high-performance athletes: diagnostic approach and minimally invasive endovascular treatment.
      • MRA allows the patient to flex the hip and may detect kinking in the iliac arteries
        • Schep G.
        • Kaandorp D.W.
        • Bender M.H.
        • Weerdenburg H.
        • van Engeland S.
        • Wijn P.F.
        Magnetic resonance angiography used to detect kinking in the iliac arteries in endurance athletes with claudication.
      • Iliac artery length during hip flexion and extension may be measured
        • Schep G.
        • Kaandorp D.W.
        • Bender M.H.
        • Van Engeland S.
        • Weerdenburg H.
        • Titulaer B.M.
        • et al.
        Excessive length of iliac arteries in athletes with flow limitations measured by magnetic resonance angiography.
      • MRA is able to assess arterial wall thickening
        • Eubank W.B.
        • Schmiedl U.P.
        • Yuan C.
        • Black C.D.
        • Kellar K.E.
        • Ladd D.L.
        • et al.
        Black blood magnetic resonance angiography with Dy-DTPA polymer: effect on arterial intraluminal signal intensity, lumen diameter, and wall thickness.
        • Maroo A.
        • O'Donnell C.J.
        Current practice and future promise for clinical noninvasive measurements of subclinical atherosclerotic disease in the elderly.
        • Choi C.J.
        • Kramer C.M.
        MR imaging of atherosclerotic plaque.
      The length of the common and external iliac artery can be accurately measured with MRA to identify excessively long vessels.
      • Schep G.
      • Kaandorp D.W.
      • Bender M.H.
      • Van Engeland S.
      • Weerdenburg H.
      • Titulaer B.M.
      • et al.
      Excessive length of iliac arteries in athletes with flow limitations measured by magnetic resonance angiography.
      • Schep G.
      • Kaandorp D.W.
      • Bender M.H.
      • Weerdenburg H.
      • van Engeland S.
      • Wijn P.F.
      Magnetic resonance angiography used to detect kinking in the iliac arteries in endurance athletes with claudication.
      Since the height of an individual influences the length of the iliac artery, the ratio of the actual length of the iliac artery to the straight line distance between the starting and the endpoint of the artery has been used to identify excessively long iliac arteries.
      • Schep G.
      • Kaandorp D.W.
      • Bender M.H.
      • Van Engeland S.
      • Weerdenburg H.
      • Titulaer B.M.
      • et al.
      Excessive length of iliac arteries in athletes with flow limitations measured by magnetic resonance angiography.
      • Schep G.
      • Kaandorp D.W.
      • Bender M.H.
      • Weerdenburg H.
      • van Engeland S.
      • Wijn P.F.
      Magnetic resonance angiography used to detect kinking in the iliac arteries in endurance athletes with claudication.
      However, further studies are needed to validate such measurements.

      Ultrasonography and colour Doppler

      Ultrasonography was reported to have a sensitivity of 84.6% for the detection of external iliac artery stenosis but only 12.5% (specificity of 66.7%) for common iliac artery disease.
      • Alimi Y.S.
      • Accrocca F.
      • Barthelemy P.
      • Hartung O.
      • Dubuc M.
      • Boufi M.
      Comparison between duplex scanning and angiographic findings in the evaluation of functional iliac obstruction in top endurance athletes.
      Ultrasound findings with endofibrosis may include hyperechoic segmental myointimal thickening in the axial view, but changes are often subtle.
      • Abraham P.
      • Leftheriotis G.
      • Bourre Y.
      • Chevalier J.M.
      • Saumet J.L.
      Echography of external iliac artery endofibrosis in cyclists.
      • Wijesinghe L.D.
      • Coughlin P.A.
      • Robertson I.
      • Kessel D.
      • Kent P.J.
      • Kester R.C.
      Cyclist's iliac syndrome: temporary relief by balloon angioplasty.
      • Abraham P.
      • Chevalier J.M.
      • Loire R.
      • Saumet J.L.
      External iliac artery endofibrosis in a young cyclist.
      It has been reported that ultrasonography has a sensitivity of about 85% in detecting endofibrosis.
      • Alimi Y.S.
      • Accrocca F.
      • Barthelemy P.
      • Hartung O.
      • Dubuc M.
      • Boufi M.
      Comparison between duplex scanning and angiographic findings in the evaluation of functional iliac obstruction in top endurance athletes.
      • Abraham P.
      • Leftheriotis G.
      • Bourre Y.
      • Chevalier J.M.
      • Saumet J.L.
      Echography of external iliac artery endofibrosis in cyclists.
      Ultrasonography has also been reported to have a sensitivity of 85.7% and specificity of 57.1% in detecting excessively long external iliac artery.
      • Alimi Y.S.
      • Accrocca F.
      • Barthelemy P.
      • Hartung O.
      • Dubuc M.
      • Boufi M.
      Comparison between duplex scanning and angiographic findings in the evaluation of functional iliac obstruction in top endurance athletes.
      Waveforms and velocity studies can detect flow limitations,
      • Giannoukas A.D.
      • Berczi V.
      • Anoop U.
      • Cleveland T.J.
      • Beard J.D.
      • Gaines P.A.
      Endofibrosis of iliac arteries in high-performance athletes: diagnostic approach and minimally invasive endovascular treatment.
      but they are usually normal unless the patients are exercised to the maximum and/or in hip hyperflexion.
      • Ford S.J.
      • Rehman A.
      • Bradbury A.W.
      External iliac endofibrosis in endurance athletes: a novel case in an endurance runner and a review of the literature.
      Intravascular ultrasonography may also be used during angiography to demonstrate the degree and distribution of intimal thickening, when the measurement of pressure gradient is inconclusive.
      • Lomis N.N.
      • Miller F.J.
      • Whiting J.H.
      • Giuliano A.W.
      • Yoon H.C.
      Exercise-induced external iliac artery intimal fibrosis: confirmation with intravascular ultrasound.

      Treatment Options

      The treatment of iliac artery disease in cyclists is challenging as there are few studies and long-term outcome data are lacking.
      • Ford S.J.
      • Rehman A.
      • Bradbury A.W.
      External iliac endofibrosis in endurance athletes: a novel case in an endurance runner and a review of the literature.
      Furthermore, these patients are usually highly competitive athletes and may expect a return to their maximal level of fitness after treatment.

      Conservative management

      Conservative management comprising of risk modifications, cycling adjustments and lifestyle changes, should be instigated with or without other therapy.
      • Moen E.
      Copore sano. An emerging occupational hazard.
      • Richardson D.M.
      Ask the Doctor: Ryan Cox and iliac artery endofibrosis.
      • Hinchfliffe R.J.
      • Palfreeman R.
      • Beard J.D.
      Vascular disease.
      Although atherosclerosis is not the cause of the problem, reduction of cardiovascular risk factors should be considered in all cases. These include the smoking cessation, assessment for hyperhomocysteinaemia and consideration of anti-platelet and cholesterol lowering drugs.
      • Ford S.J.
      • Rehman A.
      • Bradbury A.W.
      External iliac endofibrosis in endurance athletes: a novel case in an endurance runner and a review of the literature.
      • Schep G.
      • Bender M.H.
      • Kaandorp D.
      • Hammacher E.
      • de Vries W.R.
      Flow limitations in the iliac arteries in endurance athletes. Current knowledge and directions for the future.
      Cycling adjustments including modifying cycling posture and bicycle setup, reducing the level of exercise and even stopping cycling altogether should be considered when formulating a management plan. Patients should be advised strongly that conservative management is the safest treatment option while surgical and endovascular interventions are best avoided. A great challenge in the management of such patients is that most professional cyclists and many competitive amateurs may not be prepared to accept conservative treatment alone.
      • Richardson D.M.
      Ask the Doctor: Ryan Cox and iliac artery endofibrosis.
      • Hinchfliffe R.J.
      • Palfreeman R.
      • Beard J.D.
      Vascular disease.

      Surgery

      Various types of surgical intervention for iliac artery compression have been described in the literature. Surgery has often been portrayed as an alternative treatment option to conservative management despite the limited evidence based to support this approach.
      • Ehsan O.
      • Darwish A.
      • Edmundson C.
      • Mills V.
      • Al-Khaffaf H.
      Non-traumatic lower limb vascular complications in endurance athletes. Review of literature.
      • Wijesinghe L.D.
      • Coughlin P.A.
      • Robertson I.
      • Kessel D.
      • Kent P.J.
      • Kester R.C.
      Cyclist's iliac syndrome: temporary relief by balloon angioplasty.
      • Takach T.J.
      • Kane P.N.
      • Madjarov J.M.
      • Holleman J.H.
      • Nussbaum T.
      • Robicsek F.
      • et al.
      Arteriopathy in the high-performance athlete.
      The type of the operation described depended on the pathological cause of the flow limitation including iliac artery kinking, the presence of a long and tortuous artery, extrinsic compression of the vessel, endofibrosis or a combination of these processes.
      • Ehsan O.
      • Darwish A.
      • Edmundson C.
      • Mills V.
      • Al-Khaffaf H.
      Non-traumatic lower limb vascular complications in endurance athletes. Review of literature.
      • Ford S.J.
      • Rehman A.
      • Bradbury A.W.
      External iliac endofibrosis in endurance athletes: a novel case in an endurance runner and a review of the literature.
      • Schep G.
      • Kaandorp D.W.
      • Bender M.H.
      • Van Engeland S.
      • Weerdenburg H.
      • Titulaer B.M.
      • et al.
      Excessive length of iliac arteries in athletes with flow limitations measured by magnetic resonance angiography.
      • Shankar V.A.
      • Roskell D.
      • Darby C.
      Iliac artery syndrome: successful outcome after endarterectomy and vein patch angioplasty.
      • Hinchfliffe R.J.
      • Palfreeman R.
      • Beard J.D.
      Vascular disease.
      • Takach T.J.
      • Kane P.N.
      • Madjarov J.M.
      • Holleman J.H.
      • Nussbaum T.
      • Robicsek F.
      • et al.
      Arteriopathy in the high-performance athlete.
      • Abraham P.
      • Bouye P.
      • Quere I.
      • Chevalier J.M.
      • Saumet J.L.
      Past, present and future of arterial endofibrosis in athletes: a point of view.
      • Wille J.
      • de Jong J.R.
      • Moll F.L.
      • Hammacher E.R.
      • van der Zwan A.
      • Fick T.E.
      • et al.
      Endofibrosis of the external iliac artery in sportsmen clinical review and four new cases.
      Some of the previously reported procedures are described in Table 1. Minimally invasive procedures such as laparoscopic mobilisation of the external iliac artery or resection of fibrotic tissue have also been suggested.
      • Giannoukas A.D.
      • Berczi V.
      • Anoop U.
      • Cleveland T.J.
      • Beard J.D.
      • Gaines P.A.
      Endofibrosis of iliac arteries in high-performance athletes: diagnostic approach and minimally invasive endovascular treatment.
      Table 1Commonly described surgical treatments for iliac artery pathologies in cyclists.
      OperationArterial releaseShortening of the arteryResection of fibrotic sectionEndarterectomy with vein patch angioplasty
      DescriptionFreeing the iliac artery from a fixed point such as psoas artery branch and adhesionsResection of the redundant length of the iliac artery. The length and segment to be resected should be based on the surgeon's clinical judgement
      • Ford S.J.
      • Rehman A.
      • Bradbury A.W.
      External iliac endofibrosis in endurance athletes: a novel case in an endurance runner and a review of the literature.
      Resection of the fibrotic segment in the iliac artery that is causing flow limitations. Interpositional vein graft is placed if no excess artery is available for anastomosisArteriotomy and excision of the intraluminal stenotic lesion (endofibrosis). Arteriotomy is closed with vein patch angioplasty
      IndicationKinking of iliac artery secondary to anatomical tetheringLong iliac artery causing kinking or compressionPresence of fibrotic segment in the iliac artery causing flow limitationsIntraluminal stenotic lesion (endofibrosis)
      PrecautionsPresence of intravascular stenotic lesion needs to be excluded firstPresence of intravascular stenotic lesion needs to be excluded firstAvoid the use of prosthetic graftJust as in endarterectomy for atherosclerosis
      Breaching of arterial wall integrityNoYesYesYes
      Involvement of graftNoNoUsually yesVein patch
      Of all the surgical procedures, the literature only provides support for iliac arterial release. A prospective study of 23 athletic patients (22 involved in some form of competitive cycling) who underwent surgical arterial release has demonstrated that iliac artery release is safe with no reported complications. The mean hospital stay was only 3 days. Following a median follow-up of 6 months (range: 4–36 months), 12 (52%) patients were asymptomatic and 11 (48%) patients still had some residual symptoms. In the latter group, 8 (35%) patients managed to resume competition at a pre-symptom level, but 3 (13%) did not. Overall significant improvement in ABPI and systolic velocities was also present.
      • Schep G.
      • Bender M.H.
      • van de Tempel G.
      • Wijn P.F.
      • de Vries W.R.
      • Eikelboom B.C.
      Detection and treatment of claudication due to functional iliac obstruction in top endurance athletes: a prospective study.
      Overall, the evidence for surgery in iliac artery compression syndrome in cyclists is limited and thus should be avoided if possible. The use of prosthetic patches and grafts in these patients should be avoided due to the potential risks of infection and false aneurysm formation due to repetitive straining from excessive movement.
      • Giannoukas A.D.
      • Berczi V.
      • Anoop U.
      • Cleveland T.J.
      • Beard J.D.
      • Gaines P.A.
      Endofibrosis of iliac arteries in high-performance athletes: diagnostic approach and minimally invasive endovascular treatment.
      • Hinchfliffe R.J.
      • Palfreeman R.
      • Beard J.D.
      Vascular disease.
      These risks were highlighted in the recent case of a South African professional cyclist, who died at the age of 28 due to bleeding from an infected prosthetic graft previously inserted for iliac artery endofibrosis.
      • Richardson D.M.
      Ask the Doctor: Ryan Cox and iliac artery endofibrosis.
      • Hinchfliffe R.J.
      • Palfreeman R.
      • Beard J.D.
      Vascular disease.

      Endovascular treatment

      Endovascular therapy is less invasive than surgical treatment, which may result in earlier return to training and cycling and less muscle damage.
      • Giannoukas A.D.
      • Berczi V.
      • Anoop U.
      • Cleveland T.J.
      • Beard J.D.
      • Gaines P.A.
      Endofibrosis of iliac arteries in high-performance athletes: diagnostic approach and minimally invasive endovascular treatment.
      However, balloon angioplasty may only provide short-term durability and symptom relief. Early recoil may occur due to the asymmetrical intimal thickening and elasticity of endofibrosis, which is different from atherosclerosis.
      • Giannoukas A.D.
      • Berczi V.
      • Anoop U.
      • Cleveland T.J.
      • Beard J.D.
      • Gaines P.A.
      Endofibrosis of iliac arteries in high-performance athletes: diagnostic approach and minimally invasive endovascular treatment.
      • Wijesinghe L.D.
      • Coughlin P.A.
      • Robertson I.
      • Kessel D.
      • Kent P.J.
      • Kester R.C.
      Cyclist's iliac syndrome: temporary relief by balloon angioplasty.
      Although repetitive balloon angioplasty for symptomatic recurrence may help,
      • Ford S.J.
      • Rehman A.
      • Bradbury A.W.
      External iliac endofibrosis in endurance athletes: a novel case in an endurance runner and a review of the literature.
      the effectiveness and acceptability of such an approach regimen remain unknown. There is also the potential risk of intimal dissection following balloon angioplasty due to the loose attachment between the endofibrotic lesion and the media at the internal elastic lamina.
      • Ford S.J.
      • Rehman A.
      • Bradbury A.W.
      External iliac endofibrosis in endurance athletes: a novel case in an endurance runner and a review of the literature.
      • Cook P.S.
      • Erdoes L.S.
      • Selzer P.M.
      • Rivera F.J.
      • Palmaz J.C.
      Dissection of the external iliac artery in highly trained athletes.
      • Gallo D.
      • Soury P.
      • Pilsonnier D.
      • Panet M.
      • Peillon C.
      • Testarts J.
      • et al.
      Aneurism dissecant de l'arterie iliaque externe, une evolution inhabituelle de l'endofibrosie du sportif.
      Cutting balloon angioplasty may offer some advantages but further assessment of this technique is still required.
      • Giannoukas A.D.
      • Berczi V.
      • Anoop U.
      • Cleveland T.J.
      • Beard J.D.
      • Gaines P.A.
      Endofibrosis of iliac arteries in high-performance athletes: diagnostic approach and minimally invasive endovascular treatment.
      The use of endovascular stents must be avoided as repeated mechanical compression may risk the stent to disintegrate and fracture which may damage the iliac artery.
      • Ford S.J.
      • Rehman A.
      • Bradbury A.W.
      External iliac endofibrosis in endurance athletes: a novel case in an endurance runner and a review of the literature.
      Furthermore, the use of stents also raises the concern of accelerated neo-intimal hyperplasia at the stent edges due to mechanical compression and high turbulence flow during cycling.
      • Ford S.J.
      • Rehman A.
      • Bradbury A.W.
      External iliac endofibrosis in endurance athletes: a novel case in an endurance runner and a review of the literature.

      Conclusions

      Iliac artery compression should be recognised as an important differential diagnosis in competitive cyclist presenting with lower limb symptoms. Although there is no consensus on optimal management, early diagnosis may reduce unnecessary investigations, and enable the cyclist to make appropriate adjustments and decisions in treatment management. The evidence for surgical and endovascular treatments is limited, and the use of prosthetic grafts and stents should be avoided. As a randomised controlled trial may not be possible due to the relatively low number of patients, other forms of study including international registry (such as the UK Joint Vascular Research Group online ‘Iliac Artery Compression Syndrome Registry’)
      • Ford S.J.
      • Rehman A.
      • Bradbury A.W.
      External iliac endofibrosis in endurance athletes: a novel case in an endurance runner and a review of the literature.
      • Joint Vascular Research Group UK
      and prospective observational studies may be helpful.

      Conflict of Interest/Funding

      None.

      Acknowledgments

      C.S. Lim is funded by the Royal College of Surgeons of England One Year Research Fellowship.

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      Linked Article

      • Invited Commentary on Cyclists Paper
        European Journal of Vascular and Endovascular SurgeryVol. 38Issue 2
        • Preview
          This review of external iliac artery pathology in cyclists illustrates the lack of evidence available to surgeons faced with such a patient requesting treatment. While investigations may reveal thickening of the artery wall and/or kinking in flexion, does this constitute grounds for treatment? Like all muscular arteries, the iliac artery dilates in response to increased blood flow. A lack of such dilatation rather than actual narrowing may be sufficient to cause symptoms in these athletes. They may, therefore, have genuine symptoms of vascular insufficiency, even in the presence of an apparently ‘normal’ calibre artery.
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