External iliac arteriopathy is a serious vascular condition that primarily affects high-performance cyclists.
Learn more about what causes this condition and how it can be repaired from one of the nation’s leading experts in treating this condition.
Selected Podcast
Treating External Iliac Arteriopathy in Avid Bicyclists
Featured Speaker:
Dr. Kenneth Cherry
Dr. Kenneth Cherry is a board-certified vascular surgeon whose specialties include arterial disease in athletes. Transcription:
Treating External Iliac Arteriopathy in Avid Bicyclists
Melanie Cole (Host): Most elite athletes are custom to experiencing a certain degree of muscle pain and fatigue during high-intensity exercise. Recently however, some athletes, particularly cyclists, have reported symptoms of leg pain and weakness from an unexpected cause. This could be a serious vascular condition. My guest today is Dr. Kenneth Cherry. He’s a board certified vascular surgeon at UVA Heart and Vascular Center whose specialties include arterial disease in athletes. Welcome to the show, Dr. Cherry. Tell us, what is external iliac arteriopathy?
Dr. Kenneth Cherry (Guest): Good morning, Melanie. It is a narrowing of the external iliac artery in essentially elite athletes. The external iliac artery, the aorta comes down in just about the level of the belly button and just in front of the spine, divides into the common iliac artery. Then that shortly divides into the internal iliac artery that feeds the pelvis and the external iliac artery. It takes blood down to the legs. In these athletes, the external iliac artery gets narrowed, and oddly enough, it’s just the opposite of all other vascular disease. It’s because they are in such good shape and exercise so much. In this country, we see it mostly in cyclists, but it can be seen in runners, triathletes. It’s being reported in ice skaters, power ice skaters, speed ice skaters. And it’s thought it’s because the external iliac artery is tethered there at the bifurcation, then these people are so fit. Their inguinal ligament is very taut, so there’s no sliding of the artery back and forth under the ligament as there is in less fit people. The other things that go with it, hypertrophy soleus muscle. It’s really the repetitive exercise. These cyclists will cycle anywhere between 5 and 20,000 miles a year, so many of them put more miles on the bicycle than people put in their cars. They’re also putting gallons of blood past their arteries quickly with their great hearts, so it’s a stretch injury, if you will, because when they bend over, they need to lengthen that artery and they can’t do it because of that taut ligament. It’s a bit of a stretch injury and then a flow injury also. I hope I didn’t talk too long on that.
Melanie: No, that was perfect. Dr. Cherry. It’s amazing to me because the public is used to hearing that if you’re in better shape, you’re opening up your arteries and clearing them out, and this is a narrowing. Who is particularly at risk? If you’re an elite cyclist, are you then going to be more at risk if you’re putting 15-20,000 miles on your bike? Does that give you more risk or are there certain predispositions that are going to make somebody at risk for this?
Dr. Cherry: Well, it’s an excellent question, and we don’t know the answer yet. Because you could ask, “Why didn’t Lance Armstrong get it? Why didn’t other truly elite athletes get it?” And who does and who doesn’t, we don’t know yet. But we know that cyclists are seeing, speed skaters, runners, and these people are who truly fit and really put themselves up to the limit. One of the things that we, that a radiologist in here and I have sort of independently come to the conclusion is that those cyclists who have very short common iliac arteries, where their external iliac artery begins high in the pelvis, that seems to be starting to be a more prominent theme, and so we’re looking into that right now. But it’s very seldom seen in less than elite athletes. Sometimes a very high-performing amateur can get it, but it’s not very frequent.
Melanie: Dr. Cherry, how’s it treated? What do you do and what symptom? So they come to you with this claudication with this leg pain. They don’t know why. They can’t explain it. They assume it’s probably muscular or something like that. What do you do for them?
Dr. Cherry: Well, if indeed they have it and we bring them in and we put them on bicycles, they bring their pedals and we have a cycle, and they cycle until they get their symptoms. We have measured the pressure in their arteries before, and then we do it immediately afterwards to see how far it drops. Invariably, if they have it, it will drop. And then we get specialized our arteriogram, where they put a catheter in their artery and they take a picture. That’s done with the patients supine, lying on their back, as it is with all patients. But then we have these patients flex their hips for the stress position they’d have cycling, and that will accentuate any abnormalities they have. If we see the abnormality and they wish to proceed, then we will go ahead and perform an operation. If it’s localized and early in the state of this disease, we can do what’s called a patch angioplasty; sew a piece of plastic artery over that area with or without an endarterectomy, where we clear it out. It’s an interesting arterial problem because it involves all the layers of the wall. It’s not just the inside of the wall of the entire artery; all three layers are involved. If it is more extensive, then we’ll replace that part of the artery with a bypass graft. And we’re also relaxing the inguinal ligament with the small incision there and hope don’t recapitulate the injury later.
Melanie: Well, that would certainly be the goal so our athletes are able to return to their peak performance, unless they’re ready to settle down into a sedentary lifestyle, Dr. Cherry. This current treatment, this is what you’re doing. Are they able to return to their lifestyle that they have?
Dr. Cherry: The majority, around 85 percent will go back to their peak performance or performance they’re happy with. There’s been one of my patients who’s spending the last two Olympics in bicycling and has done well, and there are others that do well. Some don’t do as well, and some of it has to do -- you know, if I’d do the same operation and a 70-year-old who needs it because they can’t walk to the grocery store, they’re having [rest] pain, I probably have all sorts of leeway in the link so I can make that graft. With these very elite athletes who are putting these grafts to such stress, I have much less leeway. If you make it too short, they’ll narrow where you sew it in. It’ll pull taut there. If you make it too long, it will kink. So there’s a very narrow window in there to get the length right. And I think that has a lot to do with it also, with those that don’t recover fully.
Melanie: Do you have any advice for athletes when you first meet them? They’re worried because this is a lifestyle that they’ve developed and that they are used to. Do you have any best advice for them either before or after the surgery what they should be doing differently?
Dr. Cherry: Well, we used to have a physical therapist here who’s a very avid and very excellent cyclist, and I would link him up with these patients when they came. Because of his knowledge of bicycling and his interest in it, some of these people, he could spot and say, “Well, you know, they had their pedals fired too far forward, or, “The seat height wasn't right.” One of the things that we do, especially if it’s early, is have them work with a trainer to see if some adjustments in the seat height, where the pedals are, their mechanics might make a difference. There are some things that I’m not clever enough myself to spot, but people who deal in that, the physical therapists and the trainers can. Then it becomes a question of how much they wish to proceed. Many of these people don’t have to go to a sedentary lifestyle, but if they didn’t want the operation, would have to accept a less strenuous lifestyle. And for these young people who’ve made it their lives, that’s a hard thing to do, so most of them wish to proceed.
Melanie: Dr. Cherry, other than the fact that you are one of the nation’s foremost experts on this condition, why should someone come to UVA for their treatment?
Dr. Cherry: Well, I think because we’ve seen that it’s a rare condition. I get calls from people all the time say, “Well, we’ve got the arteriogram and they don’t have it.” Yet when we review the arteriogram, they do have it, because they’re at first subtle changes that you see. As I say, I think over the course of time, it’s like anything. If you do enough of it, you pick up subtleties and nuances that you didn’t realize just a few years ago. We published a paper about 2 years ago on this, and many of the things that we do then, we have changed subtly in the time period because of a number of patients we see. So I think that’s the benefit.
Melanie: Well, thank you so much, Dr. Kenneth Cherry. You’re listening to UVA Health Systems Radio. For more information, you can go to uvahealth.com. This is Melanie Cole. Thank you so much for listening.
Treating External Iliac Arteriopathy in Avid Bicyclists
Melanie Cole (Host): Most elite athletes are custom to experiencing a certain degree of muscle pain and fatigue during high-intensity exercise. Recently however, some athletes, particularly cyclists, have reported symptoms of leg pain and weakness from an unexpected cause. This could be a serious vascular condition. My guest today is Dr. Kenneth Cherry. He’s a board certified vascular surgeon at UVA Heart and Vascular Center whose specialties include arterial disease in athletes. Welcome to the show, Dr. Cherry. Tell us, what is external iliac arteriopathy?
Dr. Kenneth Cherry (Guest): Good morning, Melanie. It is a narrowing of the external iliac artery in essentially elite athletes. The external iliac artery, the aorta comes down in just about the level of the belly button and just in front of the spine, divides into the common iliac artery. Then that shortly divides into the internal iliac artery that feeds the pelvis and the external iliac artery. It takes blood down to the legs. In these athletes, the external iliac artery gets narrowed, and oddly enough, it’s just the opposite of all other vascular disease. It’s because they are in such good shape and exercise so much. In this country, we see it mostly in cyclists, but it can be seen in runners, triathletes. It’s being reported in ice skaters, power ice skaters, speed ice skaters. And it’s thought it’s because the external iliac artery is tethered there at the bifurcation, then these people are so fit. Their inguinal ligament is very taut, so there’s no sliding of the artery back and forth under the ligament as there is in less fit people. The other things that go with it, hypertrophy soleus muscle. It’s really the repetitive exercise. These cyclists will cycle anywhere between 5 and 20,000 miles a year, so many of them put more miles on the bicycle than people put in their cars. They’re also putting gallons of blood past their arteries quickly with their great hearts, so it’s a stretch injury, if you will, because when they bend over, they need to lengthen that artery and they can’t do it because of that taut ligament. It’s a bit of a stretch injury and then a flow injury also. I hope I didn’t talk too long on that.
Melanie: No, that was perfect. Dr. Cherry. It’s amazing to me because the public is used to hearing that if you’re in better shape, you’re opening up your arteries and clearing them out, and this is a narrowing. Who is particularly at risk? If you’re an elite cyclist, are you then going to be more at risk if you’re putting 15-20,000 miles on your bike? Does that give you more risk or are there certain predispositions that are going to make somebody at risk for this?
Dr. Cherry: Well, it’s an excellent question, and we don’t know the answer yet. Because you could ask, “Why didn’t Lance Armstrong get it? Why didn’t other truly elite athletes get it?” And who does and who doesn’t, we don’t know yet. But we know that cyclists are seeing, speed skaters, runners, and these people are who truly fit and really put themselves up to the limit. One of the things that we, that a radiologist in here and I have sort of independently come to the conclusion is that those cyclists who have very short common iliac arteries, where their external iliac artery begins high in the pelvis, that seems to be starting to be a more prominent theme, and so we’re looking into that right now. But it’s very seldom seen in less than elite athletes. Sometimes a very high-performing amateur can get it, but it’s not very frequent.
Melanie: Dr. Cherry, how’s it treated? What do you do and what symptom? So they come to you with this claudication with this leg pain. They don’t know why. They can’t explain it. They assume it’s probably muscular or something like that. What do you do for them?
Dr. Cherry: Well, if indeed they have it and we bring them in and we put them on bicycles, they bring their pedals and we have a cycle, and they cycle until they get their symptoms. We have measured the pressure in their arteries before, and then we do it immediately afterwards to see how far it drops. Invariably, if they have it, it will drop. And then we get specialized our arteriogram, where they put a catheter in their artery and they take a picture. That’s done with the patients supine, lying on their back, as it is with all patients. But then we have these patients flex their hips for the stress position they’d have cycling, and that will accentuate any abnormalities they have. If we see the abnormality and they wish to proceed, then we will go ahead and perform an operation. If it’s localized and early in the state of this disease, we can do what’s called a patch angioplasty; sew a piece of plastic artery over that area with or without an endarterectomy, where we clear it out. It’s an interesting arterial problem because it involves all the layers of the wall. It’s not just the inside of the wall of the entire artery; all three layers are involved. If it is more extensive, then we’ll replace that part of the artery with a bypass graft. And we’re also relaxing the inguinal ligament with the small incision there and hope don’t recapitulate the injury later.
Melanie: Well, that would certainly be the goal so our athletes are able to return to their peak performance, unless they’re ready to settle down into a sedentary lifestyle, Dr. Cherry. This current treatment, this is what you’re doing. Are they able to return to their lifestyle that they have?
Dr. Cherry: The majority, around 85 percent will go back to their peak performance or performance they’re happy with. There’s been one of my patients who’s spending the last two Olympics in bicycling and has done well, and there are others that do well. Some don’t do as well, and some of it has to do -- you know, if I’d do the same operation and a 70-year-old who needs it because they can’t walk to the grocery store, they’re having [rest] pain, I probably have all sorts of leeway in the link so I can make that graft. With these very elite athletes who are putting these grafts to such stress, I have much less leeway. If you make it too short, they’ll narrow where you sew it in. It’ll pull taut there. If you make it too long, it will kink. So there’s a very narrow window in there to get the length right. And I think that has a lot to do with it also, with those that don’t recover fully.
Melanie: Do you have any advice for athletes when you first meet them? They’re worried because this is a lifestyle that they’ve developed and that they are used to. Do you have any best advice for them either before or after the surgery what they should be doing differently?
Dr. Cherry: Well, we used to have a physical therapist here who’s a very avid and very excellent cyclist, and I would link him up with these patients when they came. Because of his knowledge of bicycling and his interest in it, some of these people, he could spot and say, “Well, you know, they had their pedals fired too far forward, or, “The seat height wasn't right.” One of the things that we do, especially if it’s early, is have them work with a trainer to see if some adjustments in the seat height, where the pedals are, their mechanics might make a difference. There are some things that I’m not clever enough myself to spot, but people who deal in that, the physical therapists and the trainers can. Then it becomes a question of how much they wish to proceed. Many of these people don’t have to go to a sedentary lifestyle, but if they didn’t want the operation, would have to accept a less strenuous lifestyle. And for these young people who’ve made it their lives, that’s a hard thing to do, so most of them wish to proceed.
Melanie: Dr. Cherry, other than the fact that you are one of the nation’s foremost experts on this condition, why should someone come to UVA for their treatment?
Dr. Cherry: Well, I think because we’ve seen that it’s a rare condition. I get calls from people all the time say, “Well, we’ve got the arteriogram and they don’t have it.” Yet when we review the arteriogram, they do have it, because they’re at first subtle changes that you see. As I say, I think over the course of time, it’s like anything. If you do enough of it, you pick up subtleties and nuances that you didn’t realize just a few years ago. We published a paper about 2 years ago on this, and many of the things that we do then, we have changed subtly in the time period because of a number of patients we see. So I think that’s the benefit.
Melanie: Well, thank you so much, Dr. Kenneth Cherry. You’re listening to UVA Health Systems Radio. For more information, you can go to uvahealth.com. This is Melanie Cole. Thank you so much for listening.