Endofibrosis and kinking of the iliac arteries in athletes: a systematic review

Introduction: Kinking and endofibrosis of the iliac arteries are uncommon and poorly recognized conditions affecting young endurance athletes. Deformation or progressive stenosis of the iliac artery may reduce blood flow to the lower limb and adversely affect performance. The aim of this review was to examine the existing literature relating to these flow-limiting phenomena and identify a clear, unifying strategy for the assessment and management of affected patients.

Methods: A systematic review of the literature was performed. A comprehensive search was carried out using Medline, Embase and The Cochrane Database to identify relevant articles published between 1950 and 2011 (last search date 05/08/2011). This search (and additional bibliography review) identified 413 articles, of which 367 were excluded. 46 articles were then studied in detail. Methodological quality of studies was assessed according to Scottish Intercollegiate Guideline Network criteria.

Results: Focussed history and examination can successfully identify nearly 80% of patients with iliac flow limitation. However, both provocative exercise tests and detailed imaging are also necessary to identify those in need of intervention and establish most appropriate treatment. Provocative exercise tests and duplex imaging can then be used to confirm flow limitation before detailed assessment of abnormal anatomy with MRA and DSA. These multiple imaging modalities are necessary to identify those most likely to benefit from surgery and clarify whether each patient should undergo arterial release, vessel shortening, endofibrosectomy or interposition grafting.

Conclusion: We present a systematic review of the literature together with a proposed algorithm for diagnosis and management of these iliac flow limitations in endurance athletes.