By Samantha Avery, Ellen Oakley, Braydon Dobbs, Vuong Ngo

A 54-year-old female with history of hypercholesterolemia and an unremarkable past medical and surgical history presents to the clinic with RLE claudication <1 block. The patient is an active cyclist and notes she is no longer able to cycle or walk long distances secondary to her pain and numbness. The patient is currently taking Atorvastatin. Upon physical examination, the femoral, popliteal, dorsalis pedis, and posterior tibial pulses were unilaterally non-palpable in the right leg. All patient’s pulses were visualized via doppler ultrasound. Non-invasive Ankle Brachial Index, segmental pressure, and PVR study tests indicated loss of vascularization in the right leg when compared to the left. Lab work revealed low sodium, carbon dioxide, hematocrit and BUN levels. The abnormal lab levels and physical examinations could be used to determine differential diagnoses, such as peripheral arterial disease, popliteal artery entrapment, or venous insufficiency. CT angiography was performed and revealed occlusion of the right external iliac artery at the origin and reconstitution of the common femoral arteries via the inferior epigastric and the iliac circumflex which confirmed the diagnosis of external iliac artery occlusion due to endofibrosis. Treatment was an open surgical bypass from the common iliac artery to the common femoral artery using PTFE with rings to support and maintain the graft so the patient may continue to cycle. 

External iliac artery endofibrosis is a rare, nonatherosclerotic, vascular disease that commonly affects endurance athletes. This is characterized as progressive fibrosis and hypertrophy of the intimal layer of the artery wall causing occlusion and claudication. Extreme hyperflexion at the hip joint with repetitive movements results in deformation of the iliac artery. The pathology is often misdiagnosed due in part to the young, healthy patients that present with these symptoms of what initially appears to be atherosclerotic. Intermittent claudication in older patients is common due to potential peripheral vascular disease, however, it is not common in young and healthy athletes. Endovascular treatment or repair is another plausible option, however, there is a high likelihood of failure.