C S Lim1, M S Gohel, A C Shepherd, A H Davies. 1. Imperial Vascular Unit, 4 North, Charing Cross Hospital, Imperial College, London W6 8RF, United Kingdom. cslim@doctors.org.uk
Abstract
OBJECTIVES: To review the mechanisms, diagnosis and treatment options for symptomatic iliac artery compression in cyclists. METHODS: Pubmed, Medline, Embase and Google were searched using combinations of the terms 'iliac artery disease', 'iliac artery compression', 'iliac artery stenosis', 'cyclists' and 'athletes'. RESULTS: Tethering of the iliac artery by the psoas arterial branch and fibrous tissue, and muscular hypertrophy predispose the vessel to kinking and compression during cycling. Symptoms may only be present on maximal exercise in the cycling position. Provocative exercise tests using a cycling ergometer with ankle brachial pressure index measuring has a sensitivity of 85% to detect arterial insufficiency. Magnetic resonance imaging is increasingly being used as the investigation of choice to confirm the diagnosis, although digital subtraction angiography and colour duplex ultrasonography may also help. Conservative measures including adjustments to the cycling posture and bicycle setup should be recommended to all patients. The evidence for surgical and endovascular treatments is limited and the use of prosthetic graft should be avoided. CONCLUSIONS: Iliac artery compression should be recognised as an important differential diagnosis in competitive cyclist presenting with lower limb symptoms. Although the optimal treatment strategy remains unclear, early diagnosis may reduce unnecessary investigations, and enable the cyclist to make appropriate adjustments and decisions in treatment management.
OBJECTIVES: To review the mechanisms, diagnosis and treatment options for symptomatic iliac artery compression in cyclists. METHODS: Pubmed, Medline, Embase and Google were searched using combinations of the terms 'iliac artery disease', 'iliac artery compression', 'iliac artery stenosis', 'cyclists' and 'athletes'. RESULTS: Tethering of the iliac artery by the psoas arterial branch and fibrous tissue, and muscular hypertrophy predispose the vessel to kinking and compression during cycling. Symptoms may only be present on maximal exercise in the cycling position. Provocative exercise tests using a cycling ergometer with ankle brachial pressure index measuring has a sensitivity of 85% to detect arterial insufficiency. Magnetic resonance imaging is increasingly being used as the investigation of choice to confirm the diagnosis, although digital subtraction angiography and colour duplex ultrasonography may also help. Conservative measures including adjustments to the cycling posture and bicycle setup should be recommended to all patients. The evidence for surgical and endovascular treatments is limited and the use of prosthetic graft should be avoided. CONCLUSIONS: Iliac artery compression should be recognised as an important differential diagnosis in competitive cyclist presenting with lower limb symptoms. Although the optimal treatment strategy remains unclear, early diagnosis may reduce unnecessary investigations, and enable the cyclist to make appropriate adjustments and decisions in treatment management.