VCOM Research Day Program Book 2023

Medical Resident Research Case Reports

03 External Iliac Artery Exercise Induced Vasospasm and Endofibrosis in a Female Athlete

Max Farenwald, DO; Thomas Conlee, MD; Briana Beach, DO Corresponding author: nmfarenwald@carilionclinic.org

Virginia Tech Carilion Clinic

External iliac artery exercise induced vasospasm and endofibrosis is a rare diagnosis with female athletes making up only 7% of all diagnosed cases. Following ABIs with significant changes after exercise, CTA of the external iliac artery is used to depict the anatomical structure of the vessel. Various anatomical anomalies have been described that predispose to claudication symptoms of the anterior thigh: tortuous vessel, arterial stenosis, iliopsoas hypertrophy, atherosclerotic disease, and/or endofibrosis. This case report details further evaluation and treatment following a CTA without obvious endofibrosis. A 40-year-old female triathlete presented with anterior thigh pain at the beginning of her workouts that worsened with uphill activity and was relieved shortly after rest. Patient complained of hip and quadriceps pain with weakness, loss of motion, stiffness, and radiation of pain down the anterior right leg. Initial workup showed a normal lipid profile, CBC, and CMP. MSK ultrasound showed no obvious changes to the quadriceps, IT band, TFL, or greater trochanteric bursa. Hip and lumbar plain films were

non-specific. Intra-articular right hip corticosteroid injection did not provide relief of symptoms. MRI showed no femoral avascular necrosis, fracture, or significant hip osteoarthritis with a right acetabular labral tear. CTA showed no definitive evidence of diffuse myointimal thickening to suggest endofibrosis and no hemodynamically significant stenosis. ABIs following exercise were positive for a significant drop in perfusion on the right. Conventional arteriography and intervention ultrasound was unrevealing to an expected iliac lesion. However, after 200mcg of nitroglycerin, spasm was appreciated in the right external iliac artery. Patient elected to have surgery. The external iliac artery was dissected and noted to have diffuse endofibrosis: 1cm distal to common iliac bifurcation to 1cm proximal to the inguinal ligament. External iliac artery interposition bypass with Dacron graft was performed. Patient has started her return to activity protocol at current time. Being a triathlete was part of our patient’s identity and played a major role in her mind, body, and spirit. Exercise “improved her mentally and physically.”

When the structure of the patient’s external iliac artery had undergone chronic changes and was unable to vasodilate with exercise, this patient’s function suffered, drastically. There have been multiple case reports and a few small case series that illustrate external iliac endofibrosis. Treatment with prosthetic artery replacement is less prevalent in research. Return to activity and long-term outcomes are currently being investigated. This case will provide an additional diagnostic evaluation and treatment approach to the growing research surrounding external iliac artery endofibrosis and vasospasm.

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