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Post-traumatic intima dissection and thrombosis of the external iliac artery in a sportsman
Eur J Vasc Surg 8, 645-647 (1994)
CASE REPORT
P o s t - T r a u m a t i c Intima Dissection and Thrombosis of the External Iliac Artery in a S p o r t s m a n T.A.M. Scheerlinck and P. Van den Brande
Department of Vascular Surgery, Vrije Universiteit Brussel Academic Hospital, Laarbeeklaan 101, B-1090 Brussels, Belgium
Introduction As leisure activities develop and amateur sporting activities become more and more popular, associated complications tend to increase. Vascular complications are still exceptional and post-traumatic vascular occlusion is fortunately rare. We describe a young cyclist who developed unilateral claudication after lower abdominal trauma.
Case Report
Intraarterial digital subtraction angiography of the abdominal aorta and both legs showed complete occlusion of the left external ilia artery from the common iliac artery bifurcation down to the common femoral artery (Fig. 1). The rest of the angiographic examination was normal. A further cardiovascular check-up including ECG during effort, isotopic angiocardiogram, echocardiogram, standard chest and abdomen X-ra~ functional lung examination, extensive haematological and chemical blood tests, eye-fundus examination, occuloplethysmogram, continuous wave Doppler of the carotids, echography of the abdomen, groin and
A 37-year old sportsman with no cardiovascular risk factors, cycling up to 50-100 km at least five times a week for more than 20 years, fell over his bike during training and the handle bar hit him in the left iliac fossa. The next day a haematoma was present in the left groin and buttock and he complained of paresthesia in the left leg and foot especially after an effort. Three weeks later he developed severe pain in the thigh after walking or cycling 100 m. The left foot became occasionally whitish and cold and the paresthesia persisted. On admission the femoral, popliteal and pedal pulses were absent on the left side. A Doppler examination before and after walking (4.7 k m / h , 7% inclination) showed an ankle/arm systolic pressure index of respectively 0.52 and 0.35 on the left and a constant value of 1.02 on the right. The patient started to feel pain in his left thigh after walking 50 m. Please address all correspondence to: T.A.M. Scheerlinck,Department of Vascular Surger~ V.U.B.AcademicHospital Laarbeeklaan Fig. 1. Preoperative angiogram demonstrating the thrombotic occlusionof the left externaliliac artery. 101, B-1090Brussels, Belgium. 0950~821X/94/050645+03 $08"00/0 © 1994 W. B. Saunders CompanyLtd.
646
T.A.M. Scheerlinck and P. Van den Brande
popliteal region revealed no abnormalities, except a large left and right ventricle and hypertension during effort. Two weeks later the patient was operated upon. The external iliac artery was resected and replaced by a Dacron graft of 8 m m diameter. During the operation the tissue surrounding the artery was found to be very fibrotic and inflamed. There was a thickened intimal dissection of approximatively 4 cm starting under the inguinal ligament and the lumen was obstructed by a thrombus. Postoperatively Duplex ultrasonography and intravenous digital angiography showed good flow in the graft. The right femoral and external iliac artery were found to be normal. A postoperative Doppler examination showed an ankle/arm systolic pressure index of 1.03 left and right. The patient was discharged on the 7th postoperative day, without complaints of arterial insufficiency. Three months later he began his cycling again. Building up his physical condition during the next seven months he cycled a total of 5000 km. Ten months postoperatively he restarted cycling competition. In his first race, in a vigorous attempt to win, he suddenly developed disabling claudication in the left lower extremity. Surgical exploration two days later revealed thrombotic occlusion of the Dacron graft. Both the proximal and the distal anastomosis were opened and found to be absolutely free of any narrowing due to technical error or intimal hyperplasia. Circulation through the graft was restored by balloon thrombectomy. This time we asked the patient to stop cycling. One year after his second operation the patient had a normal clinical examination and practises jogging several times a week without any complaints.
Discussion
Isolated external iliac artery lesions have been described in a long-distance runner 6 and in almost 30 cyclists.L 2 These lesions occurred on either side but always unilaterally. The lesions described in the cyclists caused only claudication during very intense efforts and were difficult to demonstrate on angiography. In cyclists a repetitive kinking of the artery in a cramped position might play an important role in the arterial wall damage. In long-distance runners a repetitive compression of the external iliac artery by the inguinal ligament is a more probable explanation, Eur J Vasc Surg Vol 8, September 1994
but no explanation is satisfactory for the unilateral character of the lesions. Intimal tearing after blunt trauma has been reported at several sites. 3-5 In this case the patient suffered a blunt trauma of the left groin and lower abdomen, accompanied by paresthesia in the left leg and only 1 month later claudication in the thigh. Peroperatively the tissues surrounding the external iliac artery were found to be fibrotic and an intimal dissection was present. The resected artery shows myxoid degeneration, sclerosis and thickening of the intima. The media contained degenerated smooth muscle fibres in a sclerous stroma. These lesions are comparable to those described by Rousselet in other cyclists.2 At several sites the lamina elastica interna was interrupted. The intima and media were neovascularised and inflammatory cells were present. These included macrophages containing hemosiderin, favouring the hypothesis of old bleeding inside the arterial wall. In this case the role of the intimal thickening and sclerosis as a promoting factor in its tearing is unclear, but one can assume it played at least some role in weakening the arterial wall rendering it more stiff and less resistant to trauma. The intimal tear probably occurred at the time of the left groin trauma but complete occlusion by a thrombus occurred only 1 month later causing severe claudication. Our patient was operated on through an extraperitoneal approach. The external iliac artery (5 cm) was resected and replaced by a Dacron prosthesis. In the case of a marathon runner who developed a thrombosis of the external iliac artery after a 3 hour run, Gallegos et al. 6 tried to preserve the original vessel: an endarterectomy was performed using a Martin loop but the vessel occluded within 12h and an ilio-femoral by-pass had to be constructed using a Dacron graft. A 2 month follow-up of the patient showed a good result and the patient started running again. On the other hand, successful percutaneous dilatation of discrete narrowings of the external iliac artery in young cyclists has been described by Monti et al. 1 However, the duration of the follow-up is not mentioned. After a resting period of 3 months, our patient was permitted to start training again. The sudden reocclusion of the graft 10 months postoperatively might have been due to repetitive trauma of the inguinal ligament on the graft, i.e. the same etiology that led to thrombosis of the native artery. We feel that young patients showing a stenotic or a diseased external iliac artery - - eventually surgically reconstructed - - due to repetitive trauma of the inguinal ligament, probably should be asked to abandon intensive sporting activities.
Post-Traumatic Intima Dissection and Thrombosis
References 1 MONTI Mr JAEGERM, GUISANY~ PAYOTM/ MASSONIS. Diagnostic de l'insuffisance art6rielle p6rif6rique chez le sportif amateur claudicant et d6pistage du "syndrome de la st6nose art6rielle iliaque isol6e chez le jeune cycliste sans facteur de risque" par examen Doppler et test sur tapis roulant. Rev Med Suisse Roman& 1984; 104: 823-830. 2 ROUSSELETM-C, SAINT-ANDREJ-P, L'HOSTE P, ENON B, MEGRETA, CHEVALIERJ-M. Stenotic intimal thickening of the external iliac artery in competition cyclist. Hum Pathol 1990; 21: 524-59.9.
647
3 BELESSDJ, MULLERDS, PEREZ H. Aortoiliac occlusion secondary to atherosclerotic plaque rupture as the result of blunt trauma. Ann Emerg Med 1990; 19(8): 922--924. 4 BUSCAGLIALC, MATOLO N~ MACBETH A. Common iliac artery injury from blunt trauma: case reports. J Trauma 1989; 29(5): 697~99. 5 SHERLOCKDJ, NIGHTINGALES, GARDECKITIM, HAMERJD. Squash injury to the internal carotid artery. Eur J Vasc Surg 1987; 1: 285-287. 6 GALLEGOSCRR, STUDLEYJGN, HAMER DB. External iliac artery occlusion--another complication of long distance running? Eur J Vasc Surg 1989; 4: 195-196.
Accepted 19 July 1993
Eur J Vasc Surg Vol 8, September 1994
CASE REPORT
P o s t - T r a u m a t i c Intima Dissection and Thrombosis of the External Iliac Artery in a S p o r t s m a n T.A.M. Scheerlinck and P. Van den Brande
Department of Vascular Surgery, Vrije Universiteit Brussel Academic Hospital, Laarbeeklaan 101, B-1090 Brussels, Belgium
Introduction As leisure activities develop and amateur sporting activities become more and more popular, associated complications tend to increase. Vascular complications are still exceptional and post-traumatic vascular occlusion is fortunately rare. We describe a young cyclist who developed unilateral claudication after lower abdominal trauma.
Case Report
Intraarterial digital subtraction angiography of the abdominal aorta and both legs showed complete occlusion of the left external ilia artery from the common iliac artery bifurcation down to the common femoral artery (Fig. 1). The rest of the angiographic examination was normal. A further cardiovascular check-up including ECG during effort, isotopic angiocardiogram, echocardiogram, standard chest and abdomen X-ra~ functional lung examination, extensive haematological and chemical blood tests, eye-fundus examination, occuloplethysmogram, continuous wave Doppler of the carotids, echography of the abdomen, groin and
A 37-year old sportsman with no cardiovascular risk factors, cycling up to 50-100 km at least five times a week for more than 20 years, fell over his bike during training and the handle bar hit him in the left iliac fossa. The next day a haematoma was present in the left groin and buttock and he complained of paresthesia in the left leg and foot especially after an effort. Three weeks later he developed severe pain in the thigh after walking or cycling 100 m. The left foot became occasionally whitish and cold and the paresthesia persisted. On admission the femoral, popliteal and pedal pulses were absent on the left side. A Doppler examination before and after walking (4.7 k m / h , 7% inclination) showed an ankle/arm systolic pressure index of respectively 0.52 and 0.35 on the left and a constant value of 1.02 on the right. The patient started to feel pain in his left thigh after walking 50 m. Please address all correspondence to: T.A.M. Scheerlinck,Department of Vascular Surger~ V.U.B.AcademicHospital Laarbeeklaan Fig. 1. Preoperative angiogram demonstrating the thrombotic occlusionof the left externaliliac artery. 101, B-1090Brussels, Belgium. 0950~821X/94/050645+03 $08"00/0 © 1994 W. B. Saunders CompanyLtd.
646
T.A.M. Scheerlinck and P. Van den Brande
popliteal region revealed no abnormalities, except a large left and right ventricle and hypertension during effort. Two weeks later the patient was operated upon. The external iliac artery was resected and replaced by a Dacron graft of 8 m m diameter. During the operation the tissue surrounding the artery was found to be very fibrotic and inflamed. There was a thickened intimal dissection of approximatively 4 cm starting under the inguinal ligament and the lumen was obstructed by a thrombus. Postoperatively Duplex ultrasonography and intravenous digital angiography showed good flow in the graft. The right femoral and external iliac artery were found to be normal. A postoperative Doppler examination showed an ankle/arm systolic pressure index of 1.03 left and right. The patient was discharged on the 7th postoperative day, without complaints of arterial insufficiency. Three months later he began his cycling again. Building up his physical condition during the next seven months he cycled a total of 5000 km. Ten months postoperatively he restarted cycling competition. In his first race, in a vigorous attempt to win, he suddenly developed disabling claudication in the left lower extremity. Surgical exploration two days later revealed thrombotic occlusion of the Dacron graft. Both the proximal and the distal anastomosis were opened and found to be absolutely free of any narrowing due to technical error or intimal hyperplasia. Circulation through the graft was restored by balloon thrombectomy. This time we asked the patient to stop cycling. One year after his second operation the patient had a normal clinical examination and practises jogging several times a week without any complaints.
Discussion
Isolated external iliac artery lesions have been described in a long-distance runner 6 and in almost 30 cyclists.L 2 These lesions occurred on either side but always unilaterally. The lesions described in the cyclists caused only claudication during very intense efforts and were difficult to demonstrate on angiography. In cyclists a repetitive kinking of the artery in a cramped position might play an important role in the arterial wall damage. In long-distance runners a repetitive compression of the external iliac artery by the inguinal ligament is a more probable explanation, Eur J Vasc Surg Vol 8, September 1994
but no explanation is satisfactory for the unilateral character of the lesions. Intimal tearing after blunt trauma has been reported at several sites. 3-5 In this case the patient suffered a blunt trauma of the left groin and lower abdomen, accompanied by paresthesia in the left leg and only 1 month later claudication in the thigh. Peroperatively the tissues surrounding the external iliac artery were found to be fibrotic and an intimal dissection was present. The resected artery shows myxoid degeneration, sclerosis and thickening of the intima. The media contained degenerated smooth muscle fibres in a sclerous stroma. These lesions are comparable to those described by Rousselet in other cyclists.2 At several sites the lamina elastica interna was interrupted. The intima and media were neovascularised and inflammatory cells were present. These included macrophages containing hemosiderin, favouring the hypothesis of old bleeding inside the arterial wall. In this case the role of the intimal thickening and sclerosis as a promoting factor in its tearing is unclear, but one can assume it played at least some role in weakening the arterial wall rendering it more stiff and less resistant to trauma. The intimal tear probably occurred at the time of the left groin trauma but complete occlusion by a thrombus occurred only 1 month later causing severe claudication. Our patient was operated on through an extraperitoneal approach. The external iliac artery (5 cm) was resected and replaced by a Dacron prosthesis. In the case of a marathon runner who developed a thrombosis of the external iliac artery after a 3 hour run, Gallegos et al. 6 tried to preserve the original vessel: an endarterectomy was performed using a Martin loop but the vessel occluded within 12h and an ilio-femoral by-pass had to be constructed using a Dacron graft. A 2 month follow-up of the patient showed a good result and the patient started running again. On the other hand, successful percutaneous dilatation of discrete narrowings of the external iliac artery in young cyclists has been described by Monti et al. 1 However, the duration of the follow-up is not mentioned. After a resting period of 3 months, our patient was permitted to start training again. The sudden reocclusion of the graft 10 months postoperatively might have been due to repetitive trauma of the inguinal ligament on the graft, i.e. the same etiology that led to thrombosis of the native artery. We feel that young patients showing a stenotic or a diseased external iliac artery - - eventually surgically reconstructed - - due to repetitive trauma of the inguinal ligament, probably should be asked to abandon intensive sporting activities.
Post-Traumatic Intima Dissection and Thrombosis
References 1 MONTI Mr JAEGERM, GUISANY~ PAYOTM/ MASSONIS. Diagnostic de l'insuffisance art6rielle p6rif6rique chez le sportif amateur claudicant et d6pistage du "syndrome de la st6nose art6rielle iliaque isol6e chez le jeune cycliste sans facteur de risque" par examen Doppler et test sur tapis roulant. Rev Med Suisse Roman& 1984; 104: 823-830. 2 ROUSSELETM-C, SAINT-ANDREJ-P, L'HOSTE P, ENON B, MEGRETA, CHEVALIERJ-M. Stenotic intimal thickening of the external iliac artery in competition cyclist. Hum Pathol 1990; 21: 524-59.9.
647
3 BELESSDJ, MULLERDS, PEREZ H. Aortoiliac occlusion secondary to atherosclerotic plaque rupture as the result of blunt trauma. Ann Emerg Med 1990; 19(8): 922--924. 4 BUSCAGLIALC, MATOLO N~ MACBETH A. Common iliac artery injury from blunt trauma: case reports. J Trauma 1989; 29(5): 697~99. 5 SHERLOCKDJ, NIGHTINGALES, GARDECKITIM, HAMERJD. Squash injury to the internal carotid artery. Eur J Vasc Surg 1987; 1: 285-287. 6 GALLEGOSCRR, STUDLEYJGN, HAMER DB. External iliac artery occlusion--another complication of long distance running? Eur J Vasc Surg 1989; 4: 195-196.
Accepted 19 July 1993
Eur J Vasc Surg Vol 8, September 1994