title: Vasospasm as a cause for claudication in athletes with external iliac artery endofibrosis.
abstract: BACKGROUND
  Exercise-induced external iliac artery endofibrosis (EIAE) is rare and has been described primarily in endurance male cyclists. Clinically, it presents as claudication during maximal exercise with quick resolution after exercise. Most patients have fibrotic changes within the external iliac artery (EIA). We describe our experience with EIAE and propose a hypothesis for the mechanism involved in the associated claudication.
  
  
  METHODS
  This was a retrospective review of athletes who presented with symptomatic EIAE requiring operative repair between 2001 and 2010. Data collected included demographic information, initial presentation, type of exercise, repair, and long-term outcome. Diagnostic studies consisted of duplex evaluation, modified exercise treadmill test, and angiography.
  
  
  RESULTS
  Eight women, presented with symptomatic EIAE. Two had bilateral EIAE. All were endurance athletes (three cyclists, one runner, and four were cyclists and runners). Median age at presentation was 42.5 years (range, 39-60 years). Median duration of symptoms was 5.5 years (range, 2-15 years). Diagnosis was confirmed with an exercise treadmill test modified to accommodate these patients' high level of conditioning and unmask the claudication. In the most recent two patients, marked EIA vasospasm was noted after exercise by duplex scanning. All patients were treated with EIA vein patch angioplasty. Follow-up ranged from 1 to 10 years. All had a normal result on the modified exercise treadmill test and resumed their athletic activities postoperatively.
  
  
  CONCLUSIONS
  This series highlights a possible mechanism to explain the claudication associated with EIAE. Vasospasm may be more important than wall thickening for the reduction of blood flow during extreme exercise in affected athletes. Routine duplex ultrasound imaging to measure EIA diameter and flow velocities before and after maximal exercise is needed to confirm this phenomenon.
authors.affiliation: Department of Cardiothoracic and Vascular Surgery, The University of Texas Medical School at Houston, Houston, TX 77030, USA. sherene.shalhub@uth.tmc.edu
authors.forename: Sherene
authors.initials: S
authors.lastname: Shalhub
authors.forename: R Eugene
authors.initials: RE
authors.lastname: Zierler
authors.forename: Watson
authors.initials: W
authors.lastname: Smith
authors.forename: Kari
authors.initials: K
authors.lastname: Olmsted
authors.forename: Alexander W
authors.initials: AW
authors.lastname: Clowes
mesh_terms: D000328:Adult; D017130:Angioplasty; D056352:Athletes; D001642:Bicycling; D001783:Blood Flow Velocity; D005080:Exercise Test; D005260:Female; D005355:Fibrosis; D006801:Humans; D007083:Iliac Artery / Q000000981:diagnostic imaging / Q000473:pathology* / Q000503:physiopathology / Q000601:surgery; D007383:Intermittent Claudication / Q000175:diagnosis / Q000209:etiology* / Q000503:physiopathology / Q000601:surgery; D008875:Middle Aged; D058729:Peripheral Arterial Disease / Q000150:complications* / Q000175:diagnosis / Q000473:pathology / Q000503:physiopathology / Q000601:surgery; D011237:Predictive Value of Tests; D011859:Radiography; D012039:Regional Blood Flow; D012189:Retrospective Studies; D012420:Running; D013035:Spasm / Q000175:diagnosis / Q000209:etiology* / Q000503:physiopathology / Q000601:surgery; D016896:Treatment Outcome; D018616:Ultrasonography, Doppler, Duplex