Treating External Iliac Arteriopathy
Unless an athlete is ready to settle down into a sedentary lifestyle, the current treatment recommendation for this condition is surgical repair of the damaged artery. External iliac arteriopathy has been most commonly treated by vascular surgeons with a procedure that involves opening or removing the narrowed section of the artery and placing a synthetic patch or natural tissue graft over the artery. Other possible surgical interventions include bypassing the damaged artery or simply releasing the inguinal ligament or psoas muscle attachments to the artery, which have also been implicated in compressing or kinking the external iliac artery. The best treatment option seems to depend upon the exact location and cause of the damage as well as the athlete's long-term goals.
Surgical Outcomes
All of the cyclists I spoke with opted for a surgical intervention that included a tissue graft or patch. They all told me that the recovery was remarkably short, although the first two weeks are anywhere from quite uncomfortable to extremely uncomfortable. One former Olympian told me, "No one tells you how much it hurts when they cut through your abdominal muscles."
Depending upon the type of surgical procedure performed, the athlete may be walking within two weeks, cycling easily on a trainer by week three and perhaps on the road in four to six weeks -- although some athletes told me that their rehab took as much as two to three months.
There are always risks of surgery and this procedure comes with the standard set, including the risk of infection, tissue rejection, return of the symptoms, or worse. In 2007, cyclist Ryan Cox died just weeks after surgery to repair his iliac artery. Because this procedure is still fairly new, there are no studies of the long-term outcomes in the cyclists who had this surgery. One cyclist I talked to said that he still feels odd aches and pains a year after his surgery and another told me that some of her symptoms have returned 5 years after surgery.
While almost all of the athletes I talked with told me they are glad they had the surgery and would do it again, it's a major decision and one I don't take lightly. I'm still doing my research, gathering information, and talking with athletes and surgeons on a regular basis. I'm finding that the best diagnostic procedure and the type of surgery recommended is highly dependent upon which surgeon you ask; they all seem to have a favorite procedure or type of graft or patch. I've been "offered" a graft from my saphenous vein (the large vein near the ankle), a Dacron patch, a bovine tissue graft (yes, from a cow), a bypass around the narrowed artery, and even a stent.
Clearly, this is not a common procedure and no one knows exactly the best approach. Outside of Europe, a handful of vascular surgeons who I've spoken with have performed this procedure on U.S. cyclists. Dr. Ken Cherry, a vascular surgeon at the University of Virgina presented a paper on this condition at the Society for Vascular Surgery meeting in 2008.
I personally worked with Dr. Jason Lee and Dr. Cornelius Olcott at Stanford Hospital.
Additional Research
- Endofibrosis of the Iliac Arteries : an Underestimated Problem (PDF)
- Arteriopathy in the High-Performance Athlete
- External Iliac Endofibrosis in Endurance Athletes
- PubMed Seach Results
While doing your own research is important and very helpful, perhaps more important is trust in your surgeon. I'll let you know what I decide to do in future updates at my Sports Medicine Blog.
Source
Chevalier et al of the Service de Chirurgie Vasculaire et Thoracique, Angers, France, iliac artery endofibrosis among elite bicycle racers, the Annals of Vascular Surgery, 1986.
Bender MH, et al. Sports-related flow limitations in the iliac arteries in endurance athletes: aetiology, diagnosis, treatment and future developments. Sports Medicine. 2004;34(7):427-42.
C. Kral, D. Han, W. Edwards, P. Spittell, H. Tazelaar, K. Cherry. Obstructive external iliac arteriopathy in avid bicyclists: New and variable histopathologic features in four women. Journal of Vascular Surgery 2002;36:565-70.
