Short- and long-term outcomes after endarterectomy with autologous patching in endurance athletes with iliac artery endofibrosis.

OBJECTIVE: Endurance athletes such as cyclists may develop intermittent claudication owing to iliac artery endofibrosis after long-lasting extreme hemodynamic challenges. This study investigated short-term (<1.5 years) and long-term (>5 years) satisfaction and safety after a surgical endarterectomy and autologous patching. METHODS: Data of endurance athletes who underwent an endarterectomy for flow limitation of the iliac artery owing to endofibrosis between 1997 and 2015 in one center were studied. Maximal cycling exercise tests, ankle-brachial index with flexed hips, echo-Doppler examination (peak systolic velocity), and contrast-enhanced magnetic resonance angiography were performed before and 6 to 18 months after surgery. Short-term and long-term satisfaction were evaluated using questionnaires. Potential patch dilatation was assessed using echo-Doppler. RESULTS: Analysis of 68 patients (79 legs; 55.7% males, median age at the time of surgery, 34 years; interquartile range, 26-41 years) demonstrated that cycling workload at symptom onset improved from 226 ± 97 to 333 ± 101 (P < .001) Watts. Peak workload increased from 326 ± 111 to 352 ± 93 Watts (P < .001). Ankle-brachial index with flexed hips increased from 0.34 (interquartile range [IQR], 0.00-0.47) to 0.59 (IQR, 0.51-0.69; P < .001). Peak systolic velocity with extended and flexed hip decreased from 2.04 m·sec-1 (IQR, 1.52-2.56 m·3sec-1) to 1.25 m·sec-1 (IQR, 0.92-1.62 m·sec-1; P < .001) and 2.40 m·sec-1 (IQR, 1.81-2.81 m·sec-1) to 1.15 m·sec-1 (IQR, 0.97-1.60 m·sec-1; P < .001), respectively. Thirty-day major complication rate was 5.1% (hematoma requiring evacuation nLegs = 2, septic bleeding from deep infection nLegs = 1, and iliac occlusion requiring thrombectomy nLegs = 1). In the short term, 91.2% of patients reported symptom reduction with a 93.7% overall satisfaction rate. After a median of 11.1 years (IQR, 7.8-17.6 years), the overall satisfaction was 91.7%; 94.5% of patients reported persistent symptom reduction. Patch dilatation of >20 mm was observed in two patients. Linear mixed model analysis revealed no alarming patch dilatation in the long term. CONCLUSIONS: Endarterectomy with an autologous patch for intermittent claudication owing to iliac artery endofibrosis in endurance athletes shows high rates of patient satisfaction and symptom reduction in both the short and long term. The risk of surgical complications or patch dilatation is mild. A surgical intervention for flow limitation of the iliac artery owing to endofibrosis is safe and successful.

Short- and long-term results of operative iliac artery release in endurance athletes.

OBJECTIVE: Endurance athletes can develop intermittent claudication due to sports-related flow limitations of the iliac artery (FLIA) caused by arterial kinking. In the present study, we investigated the short- and long-term efficacy of an operative release for iliac artery kinking. METHODS: Between 1996 and 2015, all patients with a diagnosis of FLIA due to iliac artery kinking without substantial arterial stenosis (<15%) or an excessive arterial length (vessel length to straight ratio, <1.25) who had undergone surgery were included. The short-term follow-up protocol consisted of cycling tests, the ankle brachial index with a flexed hip, and Doppler echography examinations to determine the peak systolic velocity before and 6 to 18 months after surgery. Additionally, the short- and long-term efficacy were evaluated using questionnaires. RESULTS: A total of 142 endurance athletes (155 legs; 88.4% male; median age, 26 years; interquartile range [IQR], 22-31 years) were available for analysis. In the short term, the symptoms had decreased in 83.9% of the patients, with an overall 80.3% satisfaction rate. Power during a maximal cycling test had improved from 420 W (IQR, 378-465 W) to 437 W (IQR, 392-485 W; P < .001). The symptom-free workload had increased from 300 W (IQR, 240-340 W) to 400 W (IQR, 330-448 W; P < .001). The postexercise ankle brachial index with a flexed hip had increased from 0.53 (IQR, 0.40-0.61) to 0.57 (IQR, 0.47-0.64; P = .002), and the peak systolic velocity with a flexed hip had decreased from 1.88 m/s (IQR, 1.45-2.50 m/s) to 1.52 m/s (IQR, 1.19-2.07 m/s; P < .001). Postoperative imaging studies revealed some degree kinking in 33.9%, mostly asymptomatic. The long-term results were evaluated after a median of 15.2 years (IQR, 10.9-19.5 years). The athletes had cycled an additional 125.500 km (IQR, 72.00-227.500 km), which was approximately equal to the 131.000 km (IQR, 98.250-220.000 km) cycled before the diagnosis of FLIA. On the long term, 63.9% of the athletes reported persistent reduction of complaints, with an overall 59.1% satisfaction rate. Eight patients had required reintervention, six because of treatment failure and two because of newly developed FLIA. CONCLUSIONS: Operative iliac artery release for sports-related functional kinking in the absence of stenosis or an excessive vessel length was effective for most athletes in the short and long term.