Working Diagnosis:
Right External Iliac Artery Endofibrosis

Treatment:
Surgical treatment options included Saphenous vein patch angioplasty, Stenting (contraindicated in this age group due to risk of stent failure, migration, intimal dissection, and restenosis). Non-surgical treatment options included cessation of repetitive activity (running). After consideration of options, the patient opted for angioplasty Case Photo #4 .

Outcome:
The patient underwent surgical external iliac artery angioplasty with saphenous vein graft. 4-week post-operative follow up showed no major complications. She was approved for slow return to run protocol at that time. Daily aspirin was continued for 3 months postoperatively. At 6-month follow up, the patient did not have ongoing iliac stenosis symptoms. She was running ~20 miles per week with ongoing Physical Therapy return to running protocol.

Author's Comments:
This is a rare case of iliac artery stenosis in collegiate runner. Most cases have been reported in cyclists.

Editor's Comments:
This is a rare case of iliac artery endofibrosis in a runner. Classically, iliac artery endofibrosis occurs in cyclists and speed skaters. This is thought to be due to the repeated deep hip flexion that occurs during these sports to achieve aerodynamic positioning, leading to repeated traumatic injury to the artery.
Providers should maintain a high index of suspicion for vascular insufficiency syndromes of the lower extremities (which also includes Chronic Exertional Compartment Syndrome and Popliteal Artery Entrapment Syndrome) in endurance athletes who present with vague symptoms of lower extremity fatigue and paresthesias. Frequently, resting vascular studies are normal as in this case, and further post-exercise diagnostic evaluation is required to achieve the diagnosis.

References:
Smeds, M., Bose, S., & Desikan, S. (2023, October 21). Overview of peripheral vascular problems in athletes. Uptodate. https://www.uptodate.com/contents/overview-of-peripheral-vascular-problems-in-athletes?search=peripheral%20artery%20disease%20in%20athletes&source=search_result&selectedTitle=1%7E150&usage_type=default&display_rank=1
Khan A, Al-Dawoud M, Salaman R, Al-Khaffaf H. Management of Endurance Athletes with Flow Limitation in the Iliac Arteries: A Case Series. EJVES Short Rep. 2018 Jul 20;40:7-11. doi: 10.1016/j.ejvssr.2018.06.001. PMID: 30101198; PMCID: PMC6083816.
Abraham P, Saumet JL, Chevalier JM. External iliac artery endofibrosis in athletes. Sports Med. 1997 Oct;24(4):221-6. doi: 10.2165/00007256-199724040-00001. PMID: 9339491.

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