Objectives: Flow limitation in the iliac artery (FLIA), a common cause of exertional arterial insufficiency in high-performance athletes, may be caused by endofibrosis, kinking, or extrinsic compression of the iliac arteries. Traditionally this has been described in young male cyclists. Surgical reconstruction using interposition graft replacement or patch angioplasty of the external iliac has been the mainstay of treatment in the United States, though internationally shortening alone or arterial mobilization have an increasing role. This study reviews the demographics, management, and outcomes of a large series of athletes treated for FLIA, including evolution in the population, evaluation and management. We hypothesize that there are differences in gender and athletic activities that affect the evolution and management of FLIA.
Methods: A retrospective chart review of all patients treated for FLIA was conducted at a single tertiary referral center in the years 2004-2025. Patients self-reported their primary athletic activity; patients who reported equally high rates of cycling and running were reported with triathletes. Data collected included demographics, operative details, outcomes and follow-up, including electronic health record (EHR) query for interventions elsewhere. Statistical analysis was conducted using a chi-square calculator with a p-value of < 0.05.
Results: 100 patients (36 males and 64 females) underwent were identified. The average age of patients at primary intervention (81 patients) at the study institution was 38.52 years. Patient-reported sport was cycling in 50%, running in 16% and triathlon/combined in 34% of athletes. See graph 1.
Men were more likely to be cyclists, while women were more likely to be runners or triathletes (p-value 0.0016). The left leg was more frequently affected (40%), though bilateral disease was common (32%). Women more frequently underwent interposition bypass surgery compared with men (p-value .0212). Revision for recurrence occurred in 24.7% of initial operations with no difference noted based on sport or gender, though there was a trend toward increased revisions in women. See table 1 for details.
Conclusions: The results indicate that the population presenting is evolving, with increased representation of women and of non-cycling sports. The population in this series is older and more likely female than previously documented. Women were more likely to be runners or triathletes and more likely to undergo an interposition surgery compared to patch angioplasty or inguinal ligament release. Revision remains relatively common, though as surgical approach is increasingly informed by characterization of the source of flow limitation, more nuanced interpretation of outcomes may be possible.
