159-d: STENOSIS ARTERIA ILIACA: THERAPY

Part 4: therapy

For specialists

A SHORT SUMMARY

An occupational disease in cyclists

Mechanisms playing a role:

  • Cycling position – deep aerodynamic sitting – sharp hip angle.
  • Length femoral artery. Kinking phenomenon in long vessel.
  • Thickening blood vessel wall. Scar tissue by repeated kinking.
  • Number of 50 000 km or more.

Diagnosis:

  • Typical pattern of complaints.
  • Measering differences in blood pressure and strength between good and bad leg during exercise.

Therapy:

  • Surgical

Diagnosis of stenosis of the femoral artery:

  • History
  • Examination body
  • Cycling maximum test
  • Doppler pulse volume recording (PVR)
  • Ankle/arm systolic blood pressure ratio
  • Pedal power curve.
  • Blood pressure measurement after maximal exercise
  • MRI / MRA

Treatment:
Remove kink artery
Shortening artery and remove stenosis.
Place venous patch for increase diameter.
Insert stent
Angioplastic

Practice schedule after surgery.
Aftercare
Differential diagnosis.
Therapy
Addendum
– Scan professional cyclist.
– Bicycle in the past and now
– Links.
Finally
Bibliography

DIAGNOSIS STENOSIS ILIAC ARTERY: old schedule

The most important diagnostic tests are on the one hand, the Doppler pulse volume recording (PVR) at rest and during an increasing up to a maximum effort test, and on the other hand the measurement of the ankle / arm systolic blood pressure ratio after maximum effort. During the Doppler pulse volume the blood flow is recorded through a Doppler signal graphically on a plethysmograph. It is of great importance that the patient is tested on a racing bike in the cycling specific position; completely ideal is the situation in which can be tested using the private road bike. When tested on a conventional bicycle ergometer, the symptoms often don’t occur because the kink at the height of the hip is not realized.

                     RIGHT ANKLE                                   LEFT ANKLE
Figure 2: Pulse volume recording of a cyclist with a stenosis of the left iliac artery. At rest (top) and at moderate exercise (middle) no pressure differences are observed. At maximum effort occurrence of symptoms left ankle wrist falls off (bottom) (from Pulles 1991).
Figure 3: Arterial pressures in various blood vessels immediately after a maximum load for a cyclist with a stenosis of the artery to the right external iliac artery. The top line: the right brachial artery display of blood pressure. The middle line display of the blood pressure in the arteria tibialis posterior left. The bottom line is a representation of the blood pressure in the arteria tibialis posterior to the right during a maximal exercise test. The blood pressure in the arm is somewhat higher than in the leg. The pressure difference between the right leg and the left leg is not normal and is a strong indication of the existence of a stenosis of the femoral artery. (From Chevalier et al: 1986)

Almost simultaneously with the occurrence of the specific complaints we see the disappearing pulse curves (see Figure 2). A simple test that may be performed by medical personnel accompanying cyclists is the measurement of the ankle / arm systolic blood pressure ratio after maximum effort. An appropriate cycle ergometer is after all usually available. This allowed the rider to undergo a rising load protocol, with the typical cycling position. The cyclist is instructed to continue up to the occurrence of the known symptoms. Prior to the test, one measures the systolic blood pressures of brachial artery (arm) and the two posterior arteries tibiales (leg) at rest. Immediately after the breakdown of the exercise test the rider lies on the examination couch and the aforementioned systolic blood pressures are recorded every minute until the rest values are reached again. A significantly reduced ankle/arm systolic blood pressure ratio in the symptomatic leg in comparison with the free leg during complaints, the first minutes after the effort is characteristic of the disease (see Figure 3). An ankle-brachial blood pressure ratio less than 0.9 is sufficient reason to take further action. Before you perform such tests, the athlete must obviously undergo a general physical examination. It is this definitely belongs to the palpation of the arterial pulsations in different places of the leg. In some patients, occurs in hyperflexion of the hip and a decrease in arterial pulses can be observed a souffle at the level of the groin. But these symptoms, although highly suggestive, are rarely present. Rousselet et al (1990) were able to, if the hip was bent; in 8 of the 23 patients perceive a systolic souffle in the groin region.

Some common diagnostic research methods for the detection of arterial diseases rarely result in the final diagnosis for this disease. Echo-Doppler-examination at rest, of the arterial vessels, gives an impression of the thickness of the arterial wall and the velocity of the blood flow in the blood vessels. Although such research can deliver a provisional diagnosis for the existence of the condition, its value seems very limited (1,4,6).

By arteriographic examination the lumen of the artery is made visible with the injected contrast medium. Only one cyclist thus showed deviations from the external iliac artery (3.6), Rousselet et al. (1999) could thus observe only discreet changes, if many recordings were made from a wide range of angles. On the diagnostic value of CT scan of the abdomen vessels in this disorder are still not enough data to report  a verdict  thereon. About diagnostics using of MRI and duplex scan examination exist no data all.

DIAGNOSIS  STENOSIS ILIAC  ARTERY: newer schedule

The above passage from the chapter DIAGNOSTIC is older. Below a current research schedule:

HISTORY
The typical pattern of symptoms.

PHYSICAL EXAMINATION
Souffles in the abdomen or  groin. Even in extreme flexion of the hip.
Analysis of abnormalities in the pelvis, the attitude or the lower back.
Radicular and pseudo-radicular symptoms. Think of a herniated disc in the low back.

ECHO DOPPLER
Measurement of blood flow in the femoral artery
Even with bent leg; at tightening the psoas muscle as well.
Blood flow left and right are becoming increasingly compare

MAXIMAL BIKE TEST
As much as possible in the specific cycling position.
Pedal force measurement with different left right be registered.
Submaximally there is  usually no differences in strength between  left and right.
At a certain point  one leg lags behind the other leg. As the load is increased, steadily increasing this difference. A difference in force of 10 percent or more is abnormal.

example:
Maximal exercise test:
Right leg 632 watts without complaints.
Left leg 412 Watt with complaints.
Difference between left and right is 35%.

Pedal force curves at the end of a maximal test. Right leg delivers significantly more power than the left. This observation in combination with a clear difference in blood pressure between the right and left leg is proving for an existing vascular problem

BLOOD PRESSURE DIRECTLY AFTER THE MAXIMUM EFFORT
Automatic recording of blood pressure on left and right ankle as well in one arm. While the rider remains on the ergometer with his hips in maximal flexion.
This position is achieved by placing a bench on which both feet are placed so that the hips on both sides can be held in flexion. The measurements are performed every minute and recorded. This research is perceived as unpleasant.

Once the decision for surgery is made then an MRI or MRA of blood vessels follows shortly before the operation .

What is MRI?
MRI stands for Magnetic Resonance Imaging. It is a method of making  cross-sectional images  for example of organs and joints. With MRI, we make use of a strong magnetic field and radio waves. This will be induced in the body signals. These signals are captured and converted into images by a computer. This study is not a use of X-rays. The examination is painless and, as far as is now known, not harmful to health.

What is MRA?
MRA stands for Magnetic Resonance Angiography. Here, the blood vessels  are brought into focus by means of a strong magnetic field and radio waves, and with the help of contrast fluid. For the rest, the technique is the same as that of an ordinary MRI.

 SURGERY
Only during the surgery the vessel is in view and can be palpated, at  the final state it can be reviewed and  the decision may be taken which surgery will yield the best results.

Depending on the abnormalities there are  globally  three types of surgery:

OPERATION 1:
The removal of the kink in the blood vessel. This procedure is much less invasive, because nothing is done to the vessel itself. The blood vessel is left intact, and only released from the surrounding tissue. The vessel is often attached to the psoas muscle, the hip flexor  which is extremely developed  in cyclists.
If at the time of the operation still no constriction has arisen, due to scar formation in the wall, this surgery is often sufficient and the radical complete vascular reconstruction  is not yet needed. The recovery after this procedure is, therefore, easier than with the reconstruction surgery because the risk of a post-operative bleeding in this procedure is not present. The discomfort associated with the surgery scar is the same for both operations.

OPERATION 2:
Shortening of the artery  and removal of the  stenosis.
In this procedure the artery  is shortened and  cleaned.
The too long  artery is  made shorter and the constriction by the fibrosis  is removed. After this, the artery is connected again. During the recovery period, the hip should certainly not be overstretched because of the danger  to cause a post-operative bleeding.

OPERATION 3:
Place a venous patch.
In this operation, the cross-section of the vessel increased by the placement of a venous patch. This is the most radical surgery. Beside the abdominal operation, a vein from the leg is also used. This piece of vein is sewn into the narrowed artery.
The consequences of this long-term operation are not known. The vein is much softer in texture than an artery, and therein lies the risk for the development of an aneurysm after a period of years. A thorough follow-up is highly recommended in this operation.

Example of venous patch clearly show the sewed piece of vein into the artery thus creating a larger lumen of the previously narrowed blood vessel.

STENT
A less widely used solution is to place a stent. This solution is mostly born out of necessity and because of the bend that the artery makes is not ideal.
The stent itself can kink by the millions of hip flexions per year. A well-known phenomenon is the occurrence of fibrosis, which again results in a narrowing.

A: stent with balloon is positioned.
B: balloon is inflated
C: diameter blood vessel is increased
D: stent opens and balloon is removed

BALLOON ANGIOPLASTY
Angioplasty is rarely successful. In atherosclerosis angioplastic  succeeds though the inflexible sclerotic blood vessel but upon the elastic fibrosis this procedure does not work.

“I remember the story of an Olympic competitor who had a few weeks to benefit from an angioplasty procedure and  could successful  participate in the races.

Reinier Honig:” From personal experience I have experienced the positive effect of the angioplasty stent. Then I was just one week completely free of symptoms “

Practice schedule after surgery
Practice schedule after the operation is not too extensive.
The first 4 weeks after the surgery inactive.
Week 5: 20-minute ride on the roller bank. Three times a week.
Week 6: calm cycling for an hour daily. And ride on the roller bank.
Week 7 and week 8: expand volume slowly.
After 8 weeks of training fully again.
The remaining complaints are often reduced by training.

Aftercare
7 to 10 days after surgery, there is telephone consultation with surgeon .
After surgery, there is no contact with sports doctor .
To contact sports doctor, for example, because of complaints, the operated rider should take the initiative.
General complaint is that the whole program is completed slowly.
Riders will usually ask for early surgery during the winter break when there are no races so to lose as little time as possible for the following season.

DIFFERENTIAL DIAGNOSIS
Often the complaints of an iliaca stenosis will be attributed to a disorder of the musculoskeletal system, such as tendino-myogenic radicular symptoms and syndromes. Hypertrophy of the psoas muscle can give similar symptoms. Vascular disorders should be considered include atherosclerosis,

CONCLUSIONS

This condition can only be treated surgically (3,5,6,8,9). In surgical intervention to address two problems: the too long artery is shortened in order to prevent the intermittent kinking during pedaling and the narrowing of the artery is removed  so that the artery exhibits again a normal caliber. The decision whether or not to operate is often not so difficult for a professional cyclist since he’ll be forced to end his career. For an amateur this decision can be much more difficult. The results of surgical treatment of stenosis of the femoral artery are very good. All cyclists were two to three months after the operation again fully capable of cycling without restrictions. One rider required a reoperation because two
months after the first operation the complaints restarted (8). All riders reached without exception return to their former level. Several riders were marked after surgery placings in major races and multi-day rounds on their list (4,5,6,8). Over the long term effects of such surgery, no representative data are available. Only Mosimann et al. (1985) describe the results of a five-year follow-up in a rider. they could observe no aneurysmal changes in ultrasound examination of operated vessel. Although surgical intervention is unanimously advocated as the only effective therapy, it must be remembered in these young patients for complications of the repaired vessel (2). The probability of a restenose  by neo-intimal hyperplasia and / or fibrosis  is not imaginary. Also, the development of degenerative changes, such as anastomotic aneurysms, in the long term can be an adverse consequence of a proper operation (2).

Scan of a professional cyclist in which a stent was placed in the left common iliac artery. It is clearly visible that the left artery iliaca communis (green) lies close to the musculus psoas and can come at risk during contractions of this muscle. With each contraction the psoas muscle thickened. The blood vessel that can be stuck with ramifications to the psoas is as always pulled into a kink.
In blue the right iliac artery. In  green the left artery iliaca communis.
The brightly lit circle in the green left communis  is the stent.
Display scan are always mirrored. So the left is right and right is left.

Red: musculus psoas

Yellow: spinal vertebra

Pink: iliac crest

Green: left artery ilaca communis

Blue: right artera iiaca communis

By striving for an aerodynamic position the construction of the bike is gradually changed dramatically. Then: saddle is at the same height as the handlebar. Now: saddle many cms higher than the handlebar. Result: hip angle has become increasingly sharper by this development.
Predisposing anatomic factors that cause stenosis of the iliac art while cycling.
The artery iliaca when standing upright and in hyperflexion of the hip during cycling. The dark arrow indicates the angle of the iliac artery at the hip hyperflexion while cycling.

FINALLY
We wanted to introduce you to an unusual sport specific condition that occurs with intensive sportive   cyclists. When they show the symptoms mentioned above in one leg you have to think about this cycling specific diagnosis. With the help of a relatively simple diagnostic agent the doctor is able to make the diagnosis: stenosis of the arteria iliaca externa. Although surgical intervention at all operated cyclists led to a completely symptom-free resumption of cycling at the highest level, there are hardly any data on the long-term effects of this operation. Therefore, the individual interests and needs of a cyclist with this condition will have to be carefully considered before deciding on surgery.

LITERATURE

  1. Abraham,P.,G.Leftheriotis, Y. Bourre, J.M.Chevalier, J.L. Saumet: Echografy of external iliac artery endofibrosis  in cyclists. Am J  Sports Med. 1993. 21 (6),861-863.
  2. Berge Henegouwen, D.P. van: Claudicatio intermittens bij  jeugdige patiënten (ingezonden brief). Nederlands Tijdschrift voor Geneeskunde.1992.136(24).1176
  3. Chevalier, J.M., B Enon,J.Walder, X. Barrel, J. Pillet, A. Megret,P.L’Hoste, J.P. Saint-Andre, M . Davinroy: Endofibrosis of the external iliac arteryin bicycle racers: an unrecognized pathological state. Ann Vasc Surg, 1986, 1, 297-303.
  4. Chevalier, J.M., : L’endofibrose iliaque externe du cycliste de competition. In: J.P. de Mondenard (red.): Technopathies ducyclisme. Uitgave van Ciba Geigy Frankrijk 1989, 79-88.
  5. Chevalier, J.M.,Ph. L’Hoste, F. Bouvat, A. Megret, J.P. Saint Andre, Ph.Ruault: L’ endofibrose arterielle du sportif de haut niveau formes inhabituelles. J Traumatol Sport, 1991, 8, 176- 181.
  6. Giannoukas AD, Berczi V, Anoop U, Cleveland TJ, Beard JD, Gaines PA. Endofibrosis of iliac arteries in high-performance athletes: diagnostic approach and minimally invasive endovascular treatment. Cardiovasc Intervent Radiol 2006;29(5):866-9.
  7. Lim CS, Gohel MS, Sheperd AC, Davis AH. Iliac Artery Compression in Cyclists: Mechanisms, Diagnosis and Treatment. Eur J Vasc Surg (2009) 38, 180-186.
  8. Mosimann, R., Walder, G, van Melle: Stenotic thickening of the external iliac artery: illness of the competition cyclist?Vasc Surg, 1985,19, 258-263.
  9. Pulles, H.J.W.: Claudicatio intermittans bij wielrenners. Afzien, 1991, 52, 6-8.
  10. Rousselet, M.C., J.P. Saint Andre, L’Hoste , B. Enon, A. Megret, J.M. Chevalier: Stenosis intimal  thickening of the external iliac Artery in competition cyclists. Hum pathol. 1990, 21, 524 – 529.
  11. Walder, J., Mosimann, G van Melle, R. Mosimann: A propos de l’endofibrose iliaque chez deux coureurs cyclistes. Helv Chirg.Acta, 1984, 51, 793-795.