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Int J Sports Med 1999; 20(7): 421-428
DOI: 10.1055/s-1999-8826
Review
Georg Thieme Verlag Stuttgart ·New York

Flow Limitations in the Iliac Arteries in Endurance Athletes. Current Knowledge and Directions for the Future

 G. Schep1 ,  M. H. M. Bender1 ,  D. Kaandorp1 ,  E. Hammacher2 ,  W. R. de Vries3
  • 1 St. Joseph Hospital, Veldhoven, Departments of Sports Medicine, Surgery and Clinical Physics
  • 2 Utrecht University, University Hospital Utrecht, Department of Surgery
  • 3 Utrecht University, Department of Medical Physiology and Sports Medicine
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Publication History

Publication Date:
31 December 1999 (online)

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Pain and powerless feeling in the leg during cycling may indicate a serious problem that limits the performance in cyclists. Apart from the well-known muscular and neurological origin, such complaints can also be attributed to flow limitations in the iliac arteries caused by functional lesions (kinking and/or excessive length of vessels) and/or intravascular lesions (endofibrosis). Reliable insight in the prevalence is lacking. Most intravascular lesions (≈ 90 %) are located in the external iliac artery. The diagnosis is frequently missed because physiotherapists and medical doctors are often unacquainted with the problem. The only finding in physical examination, discriminating for a vascular problem, is a bruit in the inguinal region with the thigh maximally flexed. Available diagnostic techniques are proven to be inadequate for this specific lesion, which has characteristics other than those of atherosclerotic lesions. Moreover, common techniques in a vascular laboratory do not incorporate the specific sport conditions necessary for provoking the complaints. Provocative testing on a bicycle ergometer with high intensity of exercise, combined with postexercise blood pressure measurements (at the ankle of both legs, or the ankle to arm pressure ratio) is used. Imaging techniques (echo-doppler, arterial digital subtraction angiography, magnetic resonance imaging and angiography) are necessary for proper classification of the problem. The application of specific provoking manoeuvres (hip flexion, psoas contraction, high-intensity exercise) in combination with these imaging techniques prove to be potentially valuable, although the diagnostic accuracy has to be established. Treatment should be tailored to the specific problems of the individual patient. Conservative treatment mainly indicates an advice to change sports activity. Surgical mobilization of the iliac arteries for functional lesions, and vascular reconstructions in case of intravascular lesions are possible, although long-term follow-up is lacking. Percutaneous transluminal angioplasty and intravascular stent are contra-indicated because of high risks for dissection and reactive intimal hyperplasia, respectively.

Key words:

Iliac artery - endofibrosis - claudication - cycling - endurance sports

References

  • 1 Abraham P, Chevalier J M, Leftheriotis G, Saumet J L. Lower extremity disease in sports.  Am J Sports Med. 1997;  25 581-4
    PubMedGoogle Scholar
  • 2 Abraham P, Leftheriotis G, Bourre Y, Chevalier J M, Saumet J L. Echography of external iliac artery endofibrosis in athletes.  Am J Sports Med. 1993;  21 861-3
    PubMedGoogle Scholar
  • 3 Abraham P, Saumet J L, Chevalier J M. External iliac artery endofibrosis in athletes.  Sports Med. 1997;  24 221-6
    PubMedGoogle Scholar
  • 4 Åstrand P O, Rodahl K. Textbook of Work Physiology: physiological bases of exercise. 3rd edition. New York:; McGraw Hill Book Company, 1986: 152
    Google Scholar
  • 5 van den Berg M, Boers G HJ, Franken D G, Blom H J, van Kamp G J. Hyperhomocysteinuria and endothelial dysfunction in young patients with peripheral arterial occlusive disease.  Eur J Clin Invest. 1995;  25 176-81
    PubMedGoogle Scholar
  • 6 van den Berg M, Stehouwer C DA, Bierdrager E, Rauwerda J A. Plasma homocysteine and severity of atherosclerosis in young patients with lower-limb atherosclerotic disease.  Arterioscl Tromb Vasc Biol. 1996;  16 165-71
    PubMedGoogle Scholar
  • 7 Brukner P, Khan K. Clinical Sportsmedicine. 1st edition. New York:; McGraw-Hill Book Company, 1993: 8-25
    Google Scholar
  • 8 Chevalier J M, Enon B, Walder J, Barral X, Pillet J, Megret A, L'Hoste Ph, Saint-André J P, Davinroy M. Endofibrosis of the external iliac artery in bicycle racers: an unrecognized pathological state.  Ann Vasc Surg. 1986;  1 297-303
    PubMedGoogle Scholar
  • 9 Chevalier J M, L'Hoste P M, Bouvat E, Megret A, Saint-André J P, Ruault Ph. L'endofibrose artérielle du sportif de haut niveau: formes inhabituelles.  J Traumatol Sport. 1991;  8 176-81
    PubMedGoogle Scholar
  • 10 Chevalier J M. Pathologie vasculaire du cyclistes.  Encyclopedie Medico-Chirurgicale. 1997 A10: 11-675
    Google Scholar
  • 11 Cook P S, Erdoes L S, Selzer P M, Rivera F J, Palmaz J C. Dissection of the external iliac artery in highly trained athletes.  J Vasc Surg. 1995;  22 173-7
    PubMedGoogle Scholar
  • 12 Davis R R, Hull M L. Measurement of pedal loading in bicycling: II Analysis and results.  J Biomechanics. 1981;  14 857-72
    CrossrefPubMedGoogle Scholar
  • 13 Desvaux B, Abraham P, Colin D, Leftheriotis G, Saumet J L. Ankle to arm index following maximal exercise in normal subjects and athletes.  Med Sci Sports Exerc. 1996;  28 836-9
    CrossrefPubMedGoogle Scholar
  • 14 Fitzgibbon G M, Kafka H P, Leach A J. Coronary bypass fate and patient outcome: angiographic follow-up of 5065 grafts related to survival and reoperation in 1388 patients during 25 years.  J Am Coll Cardiol. 1996;  28 616-26
    CrossrefPubMedGoogle Scholar
  • 15 Gallo D, Soury P, Plisonnier D, Panet M, Peillon C, Testarts J, Watelet J. Aneurisme dissécant de l'artère iliaque externe, une evolution inhabituelle de l'endofibrose du sportif.  J Mal Vasc. 1996;  21 95-7
    PubMedGoogle Scholar
  • 16 Glagov S, Zarins C K, Masawa N, Xu C P, Bassiouny H, Giddens D P. Mechanical functional role of non-atherosclerotic intimal thickening.  Frontiers Med Biol Engng. 1993;  5 37-43
    PubMedGoogle Scholar
  • 17 Gregor R J, Wheeler J B. Biomechanical factors associated with shoe/pedal interfaces. Implications for injury.  Sports Med. 1994;  17 117-31
    CrossrefPubMedGoogle Scholar
  • 18 von Hayek H. Das Verhalten der Arterien bei Beugung der Gelenke.  Z Anat Entwickl Gesch. 1935;  105 25-36
    PubMedGoogle Scholar
  • 19 Hiatt W R, Hirsch A T, Regensteiner J G, Brass E P. Guidelines for clinical trials in peripheral arterial disease.  Circulation. 1995;  92 614-21
    PubMedGoogle Scholar
  • 20 Hoes M JAJM, Binkhorst R A, Smeekes-Kuyl A EMC, Vissers A CA. Measurement of forces on pedal and crank during work on a bicycle ergometer at different loads.  Int Z Angew Physiol Einschl Arbeitsphysiol. 1968;  26 33-42
    CrossrefPubMedGoogle Scholar
  • 21 Hull M L, Davis R R. Measurement of pedal loading in bicycling: I Instrumentation.  J Biomechanics. 1981;  14 843-56
    PubMedGoogle Scholar
  • 22 Jäger K A, Philips D J, Martin R L. Non invasive mapping of lower limb arterial lesions.  Ultrasound Med Biol. 1985;  11 515-21
    CrossrefPubMedGoogle Scholar
  • 23 Kaandorp D W, Schep G, Kapinga K, Wijn P FF. A new segmentation algorithm for visualising complex vessel geometrics acquired by Gd-enhanced 3D MR angiography. Proc Sixth Meeting Int Soc for Magnetic Resonance in Medicine: Sydney,; 1998 811
    Google Scholar
  • 24 Kohler T R, Nance D R, Cramer M M. Duplex scanning for diagnosis of aorto-iliac and femoropopliteal disease: a prospective study.  Circulation. 1987;  76 1074-80
    CrossrefPubMedGoogle Scholar
  • 25 Lassen N A, Kamp M. Calf muscle blood flow during walking studied by the Xe-133 method in normals and in patients with intermittent claudication.  Scand J Clin Lab Invest. 1965;  17 447-53
    PubMedGoogle Scholar
  • 26 Lopez J-F, Magne J-L, Champetier J. The femoral artery and flexion of the hip joint.  Surg Radiol Anat. 1989;  11 275-81
    PubMedGoogle Scholar
  • 27 Lüscher T F, Lie J T, Stanson A W, Houser O W, Hollier L H, Sheps S H. Arterial fibromuscular dysplasia.  Mayo Clinic Proc. 1987;  62 931-52
    PubMedGoogle Scholar
  • 28 May A G, van de Berg L, de Weese J. Critical arterial stenosis.  Surgery. 1963;  54 250-9
    PubMedGoogle Scholar
  • 29 Monti M, Jaeger M, Guisan Y, Payot M, Massoni S. Diagnostic de l'insufficance artérielle périphérique chez le sportif amateur claudicant et clepistage (syndrome de la stenose artérielle iliaque isolée chez le jeune cycliste sans facteur de risque) due par examen doppler et test sur tapis roulant.  Rev Med Suisse Romande. 1984;  104 823-30
    PubMedGoogle Scholar
  • 30 Moore W S, Malone J M. Effect on flow rate and vessel caliber on critical arterial stenosis.  J Surg Res. 1979;  26 1-9
    CrossrefPubMedGoogle Scholar
  • 31 Mosiman R, Walder J, van Melle G. Stenotic intimal thickening of the external iliac artery: illness of the competition cyclist? - report of two cases.  Vasc Surg. 1985;  19 258-63
    PubMedGoogle Scholar
  • 32 Pillet J, Enon B, Reigne B, L'Hoste Ph. La plicature de l'artère fémorale commune un diagnostic différential de l'endofibrose de l'artère iliaque externe du coureur cycliste.  J Chir (Paris). 1992;  129 512-3
    PubMedGoogle Scholar
  • 33 Pils K, Bochdansky Th, Jantsch H S, Ernst E. Intermittent leg ischemia during competition cycling.  Lancet. 1990;  336 189
    PubMedGoogle Scholar
  • 34 Prince M R, Yucel E K, Kaufman J A, Harrison D C. Dynamic gadolinium enhanced three-dimensional abdominal MR-arteriography.  J Magn Reson Imag. 1993;  3 877-81
    PubMedGoogle Scholar
  • 35 Rousselet M C, Saint-André J P, L'Hoste Ph, Enon B, Megret A, Chevalier J M. Stenotic intimal thickening of the external iliac artery in competition cyclists.  Hum Pathol. 1990;  21 524-9
    CrossrefPubMedGoogle Scholar
  • 36 Rutherford R B. Standards for evaluating results of interventional therapies for peripheral vascular disease.  Circulation. 1991;  83 (Suppl. I) 6-11
    PubMedGoogle Scholar
  • 37 Rutherford R B. Vascular Surgery. W. B. Saunders Company 4th edition 1995: 18-44
    Google Scholar
  • 38 Scheerlinck T AM, van den Brande P. Post-traumatic intima dissection and thrombosis of the external iliac artery in a sportsman.  Eur J Vasc Surg. 1994;  8 645-7
    PubMedGoogle Scholar
  • 39 Schep G, Sala H AGM, Bruyninckx C MA. Leg complaints in cyclists, description of a relatively unknown occupational disease.  Geneesk en Sport. 1995;  27 182-4
    PubMedGoogle Scholar
  • 40 Scholten F G, Wensing P JW. Arterial tortuosity in the femoropopliteal region during knee flexion: a MRA study. In: Scholten FG, Wensing PJW (ed). Atherogenesis in the distal part of the femoral artery: a functional study of local factors.  Utrecht:; Thesis, Utrecht University, 1995: 53-66
    Google Scholar
  • 41 Sise J, Shackford S, Rowley R. Claudication in young adults: a frequently delayed diagnosis.  J Vasc Surg. 1989;  10 68-74
    PubMedGoogle Scholar
  • 42 Strandness D E, Dawson D L. Indirect noninvasive testing and duplex scanning. In: Strandness DE, van Breda A (eds). Vascular diseases, surgical and interventional therapy.  Livingston, ; Churchil, 1994: 139-99
    Google Scholar
  • 43 Taylor A J, Tennant W G, Batt M E, Wallace W A. Traumatic occlusion of the external iliac artery in a racing cyclist: a cause of ill-defined leg pain.  Br J Sports Med. 1997;  31 155-6
    PubMedGoogle Scholar
  • 44 Udolf E J, Klemens H B, Harrington D P, Kaufman S L, White R I. Hemodynamic significance of iliac artery stenosis: pressure measurements during angiography.  Radiol. 1979;  132 289-93
    PubMedGoogle Scholar
  • 45 Wolf E A, Summer D S, Strandness D E. Correlation between nutritive blood flow in limbs of patients with intermittent claudication.  Surg Forum. 1972;  23 238-9
    PubMedGoogle Scholar

PhD MD, W. R. de
Vries,

Dept. of Medical Physiology and Sports Medicine Utrecht University

P.O. Box 80043

NL-3508 TA Utrecht

The Netherlands

Phone: +31 (30) 2538900

Fax: +31 (30) 2539036

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