Occlusion of the Profunda Femoris Artery in Competitive Cyclists

Case 1 

A 66-year old man, who is a competitive amateur cyclist, presented with a 2-month history of left thigh claudication. The pain was consistently precipitated by intense cycling and immediately relieved by rest. He denied any calf-claudication. There was no history of trauma, cardiovascular risk factors or haematological disorders, and no significant family history.

On examination his peripheral pulses were palpable and there were no bruits. The Ankle-brachial pressure index (ABPI) was normal at rest and also following exercise on his bicycle with rollers, which reproduced his pain. Duplex scanning revealed no abnormality of the external iliac artery, but the left profunda femoris artery was not seen. Contrast-enhanced magnetic resonance angiography (CE-MRA) using a blood pool contrast agent, gadofosveset trisodium (Vasovist®), confirmed a 3–4cm occlusion of the left profunda femoris artery from its origin (Figure 1). Very subtle plaque was present in the posterior aspect of the left common femoral artery, but with no other arterial disease, this occlusion was thought to be likely due to a localised dissection caused by the repeated trauma of cycling. It was decided to adopt a conservative approach to treatment in the hope that the profunda would collateralise, and there was evidence of this on a subsequent Duplex scan performed in December 2008. The patient's pain gradually improved and he can now cycle fairly intensely for more than 60 miles at a time.

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Figure 1 CE-MRA showing occlusion of the left profunda femoris artery from its origin.

Case 2 

A 53-year old semi-professional male cyclist presented with a one-year history of right-sided thigh pain during the peaks of exercise. He had no previous history of vascular or thrombotic disease and was a non-smoker. His peripheral pulses were normal. He had normal ABPIs and Duplex scans. However, CE-MRA (Figure 2) and subsequent digital subtraction angiography demonstrated a flush occlusion at the origin of his right profunda femoris artery with very little collateralisation. Since there were no graftable vessels and the patient's symptoms occurred only at the peaks of strenuous exercise, and as he was approaching retirement, it was decided to treat him conservatively. His symptoms have gradually improved over a 15-month period.

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Figure 2 DSA showing flush occlusion of the right profunda femoris artery at its origin.

Discussion 

Thigh claudication as a result of isolated occlusion of the profunda artery has not been described before, though unilateral thigh claudication due to embolic occlusion has been previously described and studied radiologically.6, 7 Though it is not possible for us to come to any definitive conclusion as to the underlying pathology (dissection versus small plaque thrombosis versus endofibrosis) due to lack of surgical specimen or surgical exploration, our hypothesis is that the most probable cause in competitive cyclists is dissection due to repetitive trauma to the artery due to the position of flexion adopted by them. Although peripheral arterial disease is an alternative explanation, neither patient had any risk factor for peripheral arterial disease, no history of thrombo-embolic disease, normal cholesterol levels, and no evidence of atherosclerotic disease elsewhere, including on CE-MRA. Furthermore, the profunda is usually spared in patients with PAD.

As demonstrated by these cases, a normal exercise test does not exclude this diagnosis. A duplex scan might also miss the diagnosis, as illustrated by our second case. Therefore, we recommend CE-MRA as the investigation of choice to diagnose this condition, as well as iliac artery endofibrosis. Using a blood pool contrast agent enables acquisition of high-resolution images which in turn allows a greater degree of interrogation of the vessel wall. If the false lumen of an arterial dissection remains patent, the intimal flap can usually be identified with high signal opacified blood on either side. The precise extent of the dissection can also be determined including any branch vessel compromise.

Treatment depends on the severity of symptoms and the patient's sporting aspirations.

In severe cases, vein-patch repair of the profunda artery is probably the best surgical option, as it avoids the potential risks associated with prostheses and stents.

To summarise, the condition described, though rare, should be considered when investigating thigh claudication in a competitive cyclist with a normal exercise test.

Conflict of interest/Funding 

None.