Adjunctive Percutaneous Thrombolysis Followed by Definitive Open Repair for a Rare Presentation of External Iliac Artery Endofibrosis in an Elite Athlete

Background: External iliac artery endofibrosis (EIAE) is an uncommon disease affecting high performance athletes, mostly cyclists. It was first reported in 1984 in France. EIAE presents clinically with thigh and calf claudication at maximal effort. There are only few case reports of EIAE in the literature, all with varying diagnostics and treatments. We present a rare presentation of EIAE.
Case: A 49 year-old male elite competitive cyclist presented with an acute onset of left lower extremity pain while competing which persisted for three days with ambulation less than 200 feet. He had a one year history of left anterior thigh pain with maximal physical exertion. On physical exam, the femoral artery was nonpalpable and the dorsalis pedis artery had a biphasic signal. An exercise ankle-brachial index (ABI) was performed and found to be 1.3 on the right and 0.85 on the left. Upon maximal exertion, the left ABI decreased to 0.52. He was admitted and underwent a CT angiography (Figure 1) which confirmed an occluded left external iliac artery. Angiography and thrombolysis were performed successfully to identify the diseased segment. The next day, the patient underwent "endofibrosectomy" with vein patch angioplasty of the affected arterial segment (Figure 2). Also, redundancy and kinking of the artery with hip flexion was demonstrated in the operating room, therefore; an arteriectomy with re-anastomosis was performed. Final pathology confirmed diagnosis, and at three months follow-up, the patient is asymptomatic and cycling again.
Conclusions: EIAE is a rare disease process in endurance athletes. Few reports are available, however; none have presented as a complete occlusion treated with thrombolysis. Open surgery is the standard therapy because minimally invasive techniques, such as percutaneous transluminal angioplasty, have not demonstrated long term durability. In cases of iliac artery obstruction however, preoperative thrombolysis may be a useful adjunct to pinpoint the site of pathology and facilitate surgical repair.