Iliac Artery Endofibrosis: Postoperative Quality of Life Outcomes for an Elusive Disease in High-Performance Athletes

We determined the diagnostic, surgical, and long-term quality of life outcomes for patients with iliac artery endofibrosis, an underrecognized disease that affects the performance and well-being of elite endurance athletes. We performed a retrospective medical record review of all patients who had undergone surgical intervention for iliac artery endofibrosis or kinking at a single tertiary care institution. The demographics, competition and training history, radiologic findings, surgical technique, and complications were recorded. The clinical, noninvasive testing, and patency outcomes were analyzed. The modified vascular quality of life 6-item survey was administered to determine the quality of life outcomes before and after intervention. A total of 14 procedures on 12 limbs in 10 patients with iliac artery endofibrosis or kinking had been performed between 2010 and 2022. The cohort included mostly women (70%), with a mean age of 43.4 years and an average of 16.5 h/wk, 355 km/wk, and 21.6 years of endurance training before intervention. All the patients were competitors in elite (provincial, national, or international) cycling, running, or triathlon. The most common presenting symptoms were unilateral lower extremity exertional weakness and numbness. B-mode ultrasound and computed tomography findings were often reported as normal (40%). The procedures included iliac artery adhesiolysis (n = 1), inguinal ligament release (n = 2), aortoiliac shortening (n = 3), and long vein patch arterioplasty (common iliac artery, external iliac artery, femoral artery; n = 9). No major adverse limb events had occurred, except for one case of brachial artery thrombosis after preoperative diagnostic angiography. The resting ankle brachial indexes were normal before and after intervention. The mean postexercise ankle brachial index was 0.61 before intervention vs 1.08 after intervention (P = .002). The long-term primary patency had remained 100%; however, symptoms had recurred in two limbs at a mean follow-up of 5.4 years (range, 1.2-12.2 years). The modified vascular quality of life 6-item survey demonstrated significant improvement after intervention in the physical, emotional, and social functioning domains (mean score, 11.2 vs 23.2; P = .0002). Iliac artery endofibrosis and kinking is an elusive disease affecting elite and experienced endurance athletes. The diagnosis can be challenging owing to underrecognized symptoms, normal physical examination findings, and normal radiologic findings, necessitating protocolized postexercise pressure measurements. Surgical repair (aortoiliac shortening and long-vein patch arterioplasty) demonstrated excellent long-term patency with significant improvement in the physiologic and quality of life outcomes.