Iliac blood-flow restrictions causing painful and "powerless" legs are often attributed to overtraining and may develop for some time before being correctly diagnosed. In the current study, differences between actual performance parameters and performance parameters predicted from the Lamberts and Lambert Submaximal Cycle Test (LSCT) were studied in a world-class cyclist with bilateral kinking of the external iliac artery before and after surgery. Two performance-testing sessions, including a peak-power-output (PPO) test and a 40-km time trial (TT) were conducted before surgery, while 1 testing session was conducted after the surgery. Actual vs LSCT-predicted performance parameters in the world-class cyclists were compared with 82 symptom-free trained to elite male cyclists. No differences were found between actual and LSCT-predicted PPO before and after surgical intervention. However, there were differences between actual and LSCT-predicted 40-km TT time in the tests performed before the surgery (2:51and 2:55 min:s, respectively). These differences were no longer apparent in the postsurgery 40-km TT (2 s). This finding suggests that iliac blood-flow restrictions seem to mainly impair endurance performance rather than peak cycling performance. A standard PPO test without brachial ankle blood-pressure measurements might not be able to reflect iliac blood-flow restrictions. Differences between actual and LSCT-predicted 40-km TT time may assist in earlier referral to a cardiovascular specialist and result in earlier detection of iliac blood-flow restrictions.

Iliac artery endofibrosis is an uncommon condition, which should be considered in young athletes with exertional lower limb symptoms. Imaging often appears normal at rest, and the diagnosis can be missed if clinical assessment is inadequate. We report a successful case of entirely minimally invasive surgical treatment for iliac artery endofibrosis in a 41-year-old cyclist. This novel technique offers superior potential for intraoperative assessment and aids enhancement in recovery after surgery. It is likely to be particularly appealing to elite athletes.

A 53-year-old cyclist without any cardiovascular or thrombotic risk factors attended the emergency department for pain and a sensation of cold in the right leg the day after
a cycling outing. The patient started cycling at the age of 28 years and cycles approximately 40 km/day, 6 days/week; he also walks and practices cross-country skiing. The
patient was not taking any medication with a thrombotic risk. Physical examination on admission revealed a cold and cyanosed right leg, without a pulse, with a painful calf on
palpation. Angiography of the lower limbs detected thrombosis of the right external iliac artery (Fig. 1A and B). By hyperflexion of the hip peroperatively, a ‘Z’ bend in the exter-
nal iliac artery was created (Fig. 2) — one of the mechanisms that may have contributed to local endofibrosis. We suggest that this situation can occur in legs subjected to very
frequent repetitive movements. The surgical procedure consisted of complete resection of the fibrous area and interposition grafting (in contrast to atherosclerotic or embolic
lesions where the treatment would have been an angioplasty or an embolectomy with a Fogarty device). Macroscopic examination of the resected portion of the artery showed
white-coloured intimal thickening with endoluminal thrombosis (Fig. 3). Histopathologi- cal examination of the resected artery revealed thickening of the intima, with collagen
deposits, hypertrophy of the smooth muscle cells and absence of inflammatory lesions or atherosclerosis (Fig. 4A and B). The patient left the department 9 days postoperatively.
Four years later, the check-up showed an asymptomatic patient. This report is a rare case of arteriopathy in a cyclist and its mechanism, where rapid surgery improved distal
perfusion and accelerated recovery for optimum activity.

Endofibrosis of the external iliac artery is a rare cause of performance-limiting claudication in elite athletes. We describe a 47-year-old male competitive cyclist and a 52-year-old female former international triathlete, with unilateral and bilateral external artery occlusions, respectively, who presented with disabling claudication and an inability to cycle or run. Due to a long-segment occlusion, both were treated with Dacron bypass grafting. Both were able to return to competitive racing postoperatively.