Working Diagnosis:
Left External Iliac Artery Endofibrosis

Treatment:
Vascular surgery performed a left external iliac artery endofibrosectomy and patch angioplasty of the with harvest of the right great saphenous vein, without complications, two weeks after diagnosis.

Outcome:
At one-month post-op she was able to ambulate and perform daily activities without pain or neurovascular symptoms. At two months she resumed swimming and jogging without symptoms. At five months she resting and post-exercise ABIs were reassuring and she resumed all triathlon activities without limitation.
Case Photo #5

Author's Comments:
External iliac artery endofibrosis (EIAE) is a rare condition in endurance athletes. It is thought to be caused by repetitive hip hyperflexion that leads to arterial micro-trauma, intimal thickening, and psoas hypertrophy.(1-3) This results in luminal narrowing and exercise-induced ischemic symptoms such as leg pain, weakness, numbness, or a cool extremity that resolves with rest.(2,3) Resting imaging like CT, MRI, or ultrasound is often normal, necessitating exertional testing.(2) While mild cases may try conservative treatment, most require surgery.(2) Endofibrosectomy and arterial patch angioplasty (gold standard) or bypass grafting (for more complex cases) typically allow athletes to return to competitive sports.(2)

Editor's Comments:
When a vascular etiology is suspected in the context of exertional leg symptoms, dynamic or pre- and post-exertional diagnostic testing is warranted. Ankle-brachial index (ABI) measurements are a simple, cost-effective, and reliable initial screening tool for vascular compromise. A post-exercise decrease in ABI of 0.4 or greater warrants further evaluation with duplex ultrasound, computed tomography angiography (CTA) or magnetic resonance angiography (MRA).(3) In this case, the severity was highlighted by a nearly 0.8 drop in ABI and the presence of a cold extremity- findings that should raise strong concern for significant vascular pathology.

References:
1. Gahwiler R, Hirschmuller A, Grumann T, Isaak A, Thalhammer C. Exercise induced leg pain due to endofibrosis of external iliac artery. Vasa. 2021 Feb;50(2):92-100. doi: 10.1024/0301-1526/a000909. Epub 2020 Sep 15. PMID: 32930655.
2. Martinez A, Wells BJ. Vascular Disease Patient Information Page: External iliac artery endofibrosis. Vasc Med. 2022 Apr;27(2):207-210. doi: 10.1177/1358863X221076565. Epub 2022 Feb 15. PMID: 35168434.
3. Veraldi GF, Macri M, Criscenti P, Scorsone L, Zingaretti CC, Gnoni M, Mezzetto L. Arterial endofibrosis in professional cyclists. G Chir. 2015 Nov-Dec;36(6):267-71. doi: 10.11138/gchir/2015.36.6.267. PMID: 26888703; PMCID: PMC4767374.

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