Working Diagnosis:
right external iliac artery with endofibrosis with infrarenal aortic dissection.

Treatment:
The treatment for this patient started with three months of metoprolol and complete rest from exercise to allow the intimal flap of the dissection to mature. Vascular surgery was performed with open aortoiliac reconstruction with distal aortic septectomy and patch angioplasty of the distal aorta, right external iliac artery, and common femoral artery. Inguinal ligament ligation was also performed. Case Photo #3 Case Photo #4 Case Photo #5

Outcome:
Follow up CTA and ABIs 16 weeks after surgery were normal, including recovery time following exercise ABIs. The patient was cleared at sixteen weeks to return to all activities. Despite normal imaging and ABIs, the patient continued to have some right leg pain and fatigue with high cardiac output activities. She is able to participate in all activities. Physical therapy has been helpful.

Author's Comments:
This is the first known case of external iliac artery endofibrosis (EIAE) with subsequent aortic dissection.
EIAE is an uncommon condition and challenging to diagnose. It is most often seen in elite cyclists, but has been reported in recreational athletes, including runners. Repetitive mechanical stress can cause the arteries to stretch, kink, & scar resulting in decreased blood flow & ischemia. Symptoms include pain, weakness, loss of power, and fatigue with extreme activity, but typically resolve with rest. A typical work-up includes exercise ABIs and CTA. Conservative treatment consists of activity modification. Surgical treatment options include patch angioplasty, stents, or bypass grafting. Atraumatic aortic dissection is exceptionally rare in a young healthy person without a history of connective tissue disorder.

Editor's Comments:
External iliac artery endofibrosis (EIAE) is a rare disorder typically affecting endurance athletes. Published data is limited to mostly case reports. Originally described in cyclists in the 1980’s, it has since been reported in other types of endurance athletes. Given the prevalence in cyclists, the pathophysiology historically was thought to entail repetitive trauma causing elongation/stretching and deformation of the artery due to repetitive hyperflexion of the hip. Additional factors that are hypothesized to augment the mechanical forces on the vessel include high cardiac output that creates shear stress to the vessel and triggers endothelial dysfunction. Other than the mechanical factors imposed by repetitive hyperflexion of the hip, the only other risk factor that has been identified is a hypertrophied psoas muscle on the affected side. Arterial dissection has been documented as a rare complication of EIAE (

References:
Callahan M, Campbell J. Spontaneous Infrarenal Aortic Dissection in an Athlete Managed Emergently With Endovascular Stent Grafts, Occluders, and Femoral-Femoral Artery Bypass. J Am Osteopath Assoc. 2018 Dec 1;118(12):827-831. doi: 10.7556/jaoa.2018.176. PMID: 30476995.
Ford SJ, Rehman A, Bradbury AW. External iliac endofibrosis in endurance athletes: a novel case in an endurance runner and a review of the literature. Eur J Vasc Endovasc Surg. 2003 Dec;26(6):629-34. doi: 10.1016/j.ejvs.2003.08.003. PMID: 14603423.
Peake LK, D'Abate F, Farrah J, Morgan M, Hinchliffe RJ. The Investigation and Management of Iliac Artery Endofibrosis: Lessons Learned from a Case Series. Eur J Vasc Endovasc Surg. 2018 Apr;55(4):577-583. doi: 10.1016/j.ejvs.2018.01.018. Epub 2018 Mar 13. PMID: 29548540.
Veraldi GF, Macri M, Criscenti P, Scorsone L, Zingaretti CC, Gnoni M, Mezzetto L. Arterial endofibrosis in professional cyclists. G Chir. 2015 Nov-Dec;36(6):267-71. doi: 10.11138/gchir/2015.36.6.267. PMID: 26888703; PMCID: PMC4767374.

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