Iliac Artery Syndrome: Successful Outcome After Endarterectomy and Vein Patch Angioplasty
Article Outline
Abstract
Iliac artery syndrome has been described in competition cyclists or other endurance athletes who present with claudication during intense activity. It may be difficult to diagnose, as the patient's pulses and ankle brachial pressure index (ABPI) are often normal at rest. We report a case of external iliac artery stenosis in a 30-year-old male competition cyclist. Exploration revealed a markedly hypertrophied psoas muscle with a thickened external iliac artery. The course of the EIA was markedly angulated down into the pelvis and then up over the prominent psoas muscle. It was treated successfully by iliac endarterectomy and vein patch angioplasty.
Keywords: Iliac artery syndrome, Competitive cyclists, Surgery, Long-term outcome
1. Introduction
Competition cyclists can develop this rare vascular syndrome and present with claudication during intense cycling activity. The syndrome may be difficult to diagnose, as the patient's pulses and ankle brachial pressure index (ABPI) are often normal at rest. A similar presentation has also been described in endurance athletes including long distance runners.
We report a case of external iliac artery stenosis in a 30-year-old male competition cyclist treated by endarterectomy and vein patch angioplasty with a successful long-term outcome after surgery.
2. Case Report
The patient gave a 2-year history of fatigue in his left leg, which was global, affecting muscle groups in the anterior and posterior thigh and below the knee. This problem was quite consistent but only initially occurred only on extreme exercise related to his cycling. More recently the patient was able to provoke his symptoms by rapid climbing of stairs. Rest always relieved the leg pain rapidly. On examination his pulses were completely normal and there was no neurological abnormality. His ankle pressures at rest were normal. A provisional diagnosis of iliac artery entrapment syndrome was made and the patient attended our vascular laboratory for further studies.
Ankle pressures after 1
min of treadmill exercise at 10° of incline, were greater than 1. He was then exercised on an exercise bike using fifth gear at approximately 30–40miles/h. His left leg began tiring after 30s, and at 90s his cycling pace slowed down and he stopped at 2min. His ABPI post-cycling was 0.31 in the posterior tibial artery (PT) and 0.43 in the anterior tibial artery (AT). The ABPI in the right (asymptomatic) leg were more than 1. Duplex assessment of the iliac vessels on the left showed no significant disease in the common iliac artery (CIA). However, turbulent flow was detected in the distal external iliac artery (EIA) indicating an approximate 50% stenosis. An angiogram showed a diffuse smooth stenosis of the left EIA 5–6cm from its origin (Fig. 1). All other vessels on both sides were normal. After discussion with the radiologists it was felt that an angioplasty of the narrowing seen in the left EIA was not likely to be helpful in the long-term. Management options were to stop competitive cycling or a surgical approach aimed at improving his symptoms. The patient opted for surgery and an informed consent was obtained for exploration of the left EIA via a retroperitoneal approach.
Fig. 1.
Angiography showing a smooth stenosing lesion in the left external iliac artery.
A para-rectal incision was made in the left iliac fossa and the peritoneum displaced medially. Exploration revealed a markedly hypertrophied psoas muscle with a thickened EIA, 5cm after its origin from CIA becoming normal again a few centimetres above the inguinal ligament. The course of the EIA was markedly angulated down into the pelvis and then up over the prominent psoas muscle. At the apex of this angulation was a large branch from EIA to the hypertrophied psoas muscle and this artery was tethering the EIA and causing the angulation.
Heparin 5000IU was administered prior to application of clamps to the origin of the EIA and to the EIA at the inguinal ligament. The enlarged artery to psoas was divided and the EIA immediately retuned to a more natural course over the psoas muscle. An arteriotomy was made in a normal part of the artery and extended through the narrowed area. A white intimal thickening that tapered off towards normal artery above and below, filled the artery lumen. This material was easily removed as in endarterectomy for atherosclerosis. The arteriotomy was closed using a reversed vein patch, retrieved from the upper thigh, extending from CIA to the inguinal ligament. Good flow after the completion of the procedure was noted with return of all pulses in the limb. An infusion of intravenous heparin was continued for 24h. The resting ABPI at the AT and DP were greater than 1 at the time of discharge 3 days later.
Histology of the endarterectomy specimen demonstrated a 5–6cm segment of grossly thickened intima with intimal fibromuscular expansion associated with some myxoid material without any evidence of an atheroclerotic process such as the presence of foam cells, necrosis or lipid plaques (Fig. 2).
Fig. 2.
Endarterectomised segment of grossly thickened intima from the involved external iliac artery. Microscopy showing intimal fibromuscular expansion with myxoid material and no evidence of atherosclerosis.
Six weeks post-procedure the patient was able to climb stairs without any discomfort and Duplex confirmed a normal calibre EIA. Six months post-procedure he had returned to cycling and was able to cycle up to 10miles without any pain. A repeat exercise test carried out exactly as before showed an ABPI of 0.96 on the previously symptomatic limb and greater than 1 on the asymptomatic limb.
On his follow-up 3 years after surgery the patient had returned to competitive cycling and was performing well without any recurrence of his symptoms. Duplex showed a normal calibre EIA on the previously symptomatic side and a full challenge in the vascular laboratory as before showed no further change in his ABPI.
3. Discussion
Stenosing intimal thickening of the EIA in cyclists has been recognised.1, 2 The mechanism is thought to be due to repetitive movements involving the psoas muscle with hyperflexion at the hip producing angulation and turbulence in the EIA giving rise to the myo-intimal hyperplasia.1 It would seem that the presence of a vessel to the psoas muscle might be an important aetiological factor as the great majority of competitive cyclist do not develop this syndrome. It is of note that his vessel is not often seen during EIA dissection for atherosclerotic disease or for renal transplantation.
These patients do not experience any ischaemic symptoms except when undertaking intense exercise and this makes any decision with regard to intervention difficult. These patients do not have the usual predisposing factors for vascular disease that can be managed medically. Therefore, options for this condition include conservative, interventional and surgical approaches. Any decision to intervene surgically should be based on the patient's assessment of the risk of surgery versus his perceived benefit.
Patients presenting with iliac artery syndrome have been offered either percutaneous transluminal angioplasty (PTA) or surgery. Surgical methods include release of the EIA from the psoas by dividing the branch tethering it to the muscle, shortening of the EIA, resection of the stenotic area with interposition of a vein graft and endarterectomy with vein patch angioplasty. Experience with these surgical options is limited and no one surgical approach or PTA has been shown to be the best option for this condition.
PTA of a stenotic3 or thrombosed4 EIA has been reported to provide temporary relief of symptoms that can allow a cyclist to return to competition.2, 3 There is, no long term follow to show if this is a good and durable treatment. Our patient was eager to return to competitive cycling and a PTA would not deal with the underlying aetiological factors. Hence, we felt that a PTA would be likely to offer little long-term benefit. Therefore, we offered surgery and carried out endarterectomy with vein patch angioplasty via a retroperitoneal approach.
A successful immediate and a long-term outcome in our patient's case has shown that endarterectomy with vein patch angioplasty provides good relief of symptoms and allows the cyclist to return to competitive cycling.
References
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- . External iliac artery endofibrosis: a 40-year course. J Sports Med Phys Fitness. 1997;37(4):297–300
- . Cyclist's iliac syndrome: temporary relief by balloon angioplasty. Br J Sports Med. 2001;35(1):70–71
- . Complete external iliac artery occlusion in a 34-year-old cyclist. Eur J Vasc Endovasc Surg. 2002;23(4):376–377
PII: S1533-3167(06)00052-5
doi:10.1016/j.ejvsextra.2005.06.006
© 2006 Elsevier Ltd. All rights reserved.
