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 2010-2011 E.J. Wylie Traveling Fellowship Report

Jason T. Lee, MD
Stanford University School of Medicine
Stanford, California

Title:  Vascular disorders in high-performance athletes: A rare but disabling problem

The vascular consequences of overuse or stress injuries in high-performance athletes include arterial ischemia, venous congestion, and functional impairment. While rarely life- or limb-threatening, vascular compromise can significantly limit a young athlete’s career. Elite cyclists have been reported to develop external iliac artery endofibrosis, long distance runners and sprinters suffer from functional popliteal entrapment, and a variety of throwers/swimmers/rowers/surfers may be limited by all forms of thoracic outlet syndrome. Vascular intervention on these patients can provide long-term benefit to these young athletes, but the diagnostic algorithms and surgical outcomes are sporadically reported due to the rarity of the conditions. 

In my early years on the faculty in the Division of Vascular Surgery, I had the privilege of providing care for many student-athletes here at Stanford, as well as local and national professional and semiprofessional athletes. This group of young patients has also included competitive high-performance cyclists. This opportunity and referral practice was initially developed by my clinical mentor, Cornelius Olcott, IV, MD, Emeritus Professor of Surgery, as he spent the past three decades in Northern California treating vascular athletic disorders. With the desire to more rigorously understand these rare conditions, I applied for the E. J. Wylie Traveling Fellowship and was fortunate to receive the award in 2010-2011. I hoped to gain a more comprehensive understanding of athletic vascular disorders, particularly in the elite cyclists with regards to innovative radiographic workups, medical, surgical, and endovascular treatments, and the underlying pathophysiology of these disabling disorders. 

The rarity of these conditions and isolated case reports in the US made it challenging to study patterns of disease of endofibrosis, and after reviewing the world’s literature I felt the experts were in France, where it is no surprise the high proportion of cyclists. Honestly I was not prepared for the vast surgical experience after visiting those centers. The original reports of external iliac endofibrosis came from Drs. Chevalier and Feugier in Lyon, France, as well as some work done in Angers, France by Pierre Abraham. Upon receiving the E.J. Wylie Fellowship, I reached out to our French vascular colleagues, and they were more than accommodating in hosting me for my traveling fellowship. 

I started a two week trip in 2011 to visit Lyon, Strasbourg, and Angers with the plan to spend time in the vascular clinics, operating rooms, angiography suites, an international meeting occurring on the time, and arranged as many visits with as many surgeons as possible. I arrived in the late spring of 2011 to meet with Dr. Feugier at the Service de Chirurgie Vasculaire, Hôpital E Herriot, in Lyon, France. We started with a clinic visit day, and I was immediately struck by the fact that a cycling trainer rigged with a wattmeter was sitting in Dr. Feugier’s office, indicative of the volume of cyclists he sees that require evaluation. In the waiting room that afternoon were several well-conditioned young men and women who clearly were not the typical vasculopath seen in our usual outpatient settings.

The largest series reported in the US has been from Dr. Ken Cherry, who has reported on 20 patients operated upon for external iliac endofibrosis. I casually asked Dr. Feugier while joining him in the clinic evaluating four different cyclists all with differing amounts of disability, “How many patients have you operated upon?” I was expecting him to reveal he’d operated on about 100 patients, estimating it might be four or five-fold our experience in the US. He said he operated on over 600 cyclists over the past 20 years, and I suddenly realized I now had a unique opportunity to understand the pathophysiology and outcomes better than I could have imagined.

We discussed at length in the clinic and in the operating room the following day, his algorithm for workup of the cyclist with leg discomfort, loss of power, and thigh claudication. One of the key diagnostic pearls is the cyclist must reproduce his symptoms on the bicycle, and the stress of cycling must document a change in ABIs. Having patients walk or run on a treadmill does not bring about the physiologic change the elite cyclists experience, as those are different muscles utilized. As I’ve noted in patients referred to me with suspicion for iliac endofibrosis, most referring physicians will obtain traditional exercise treadmill ABIs. The importance of stressing the cyclist in the environment he/she develops symptoms was a key lesson, and I realized that in creating a referral center for these patients at home would require our vascular lab to invest in a trainer to allow patients to be tested appropriately.

We discussed further the need for better imaging after the diagnosis is suspected, and debated the merits of positional angiography versus CT scanning. Based on my own experience with these techniques, it was clear a standard was not agreed upon nor created. While enjoying some local Lyon wines and foods, we had an extensive discussion over dinner with Dr. Feugier’s partners as to the wide range of presentations and anatomies that the cyclists present with: narrowing, lengthening, shortening, kinking, and tight inguinal ligaments. The heterogeneity of these presentations makes the operations as varied, and I also realized that some standardization of diagnosis would be necessary for creation of registries and follow-up.

During my travels in France I was able to travel on the Eurotrain, which I realized was a great way to see the countryside, and after traveling through Strasbourg with my prior colleagues and great friends Nabil Chakfe and Fabien Thaveau, world expert surgeons at laparoscopic aortic surgery, I next headed towards Angers on the western border of France. Here Pierre Abraham and Jean Picquet work in the university hospital there, and I was able to reconnect with Dr. Picquet, who was a visiting scholar at Stanford when I was a fellow in 2004. I was able to spend a day in Angers operating with Dr. Picquet, and spent clinic time with Dr. Abraham, who runs an exercise physiology vascular lab testing cyclists. With Dr. Abraham I learned the subtlety of the simultaneous pressure measurements of all four limbs at baseline, and after maximizing the cycling effort. I have since replicated Dr. Abraham’s algorithm for testing the cyclists, namely starting with a 5 minute 50 watt warm-up, then increasing 50 watts every 3 minutes until the cyclist is no longer able to ride. Typical symptoms come on at about 200 watts, and most elite cyclists I’ve tested since returning back to Stanford can get to 350 watts.

The most interesting finding that I have not yet been able to fully explain from a physiologic standpoint, is that the cyclists will normally drop their ABI to the 0.7 level, and return immediately after 1 minute. The pathologic leg (or symptomatic) is not able to do that, and often drops below 0.5, and takes several minutes to return to normal. I have noted this pattern now testing several cyclists in the US, and hope to report on our own series of US patients. Imaging was also importantly discussed in Angers, and again debate about positional CT scans versus angiograms are not clearly favored when several of the partners in the Angers group were polled. I was sad to see my trip ending after gathering so much information, and seeing several operations, and meeting several cyclists in clinic, but was confident I had gained valuable insight to provide better care to US patients.

By spending time and therefore benefiting from the collective experience of this distinguished group of surgeons in France, many of whom I would have never had the opportunity to interact with at US meetings, I am fortunate to have been the 2010-2011 recipient of the E.J. Wylie Traveling Fellowship. In the spirit of international collaborations that such fellowships create, I have continued my interactions with Dr. Feugier, and will be working with him on numerous upcoming retrospective reviews of his immense series of cyclists for upcoming meetings. First we will be reviewing the midterm outcomes of cyclists operated upon, documenting exactly what percentage of patients get back to ultracompetitive levels. We also will review imaging pre- and post-op to study the iliac kinking that occurs, which is poorly understood, and even less well understood is the optimal surgical treatment. Having a series of CT-A or angiographic studies in provocative positions, and the wide variety of surgical reconstructions for each of these types of anatomies can give us a better idea the optimal surgical approach.
 
My interactions with Dr. Abraham, while illustrative, created many more questions for me, but did allow me to replicate his ABI measuring system with immediate 4 limb BP measurements in our own clinic now, and therefore trying to quantify the actual drop in ABI that is suggestive of significant endofibrosis. As noted above, one of my most striking findings is that a drop up to 0.7 from baseline is actually normal in the elite athlete, which goes against all prior observations for atherosclerotic inflow disease. As I test more patients in our own lab in the US and confirming measurements from our French colleagues, this finding could be of significant clinical relevance to all surgeons caring for these complex patients.

Finally, the camaraderie and goodwill created by my visit to France and my friends Drs. Feugier, Chakfe, Thaveau, Abraham, and Picquet, and Angers, created a great set of colleagues and friends, and has had a meaningful impact in my future interest in visiting the country again. At this time I am planning on taking sabbatical in the year 2015 in France, to continue to work on these projects and have direct access to the patients, databases, and diagnostic algorithms from the world’s experts. This is the wonderful opportunity the E.J. Wylie Traveling Fellowship provided me, and certainly without my trip and contacts made in 2011, I wouldn’t have been able to set up these collaborations.
 
I hope therefore to provide to our local and national region with the most advanced vascular care available for these complex and disabling vascular problems in these cyclists, and will continue to work closely with US colleagues also interested in these patients. A national registry is likely necessary to truly understand the nuances of the treatment of these patients. This expertise will also and has already catalyzed new collaborations at my home institution with experts in the sports medicine, orthopedic, and physical medicine/rehabilitation departments, and provide better care for athletes at all age ranges. I am extremely and forever grateful for the privilege and opportunity provided to me by the E.J. Wylie Fellowship, and I believe it significantly enhanced my early career as well as the continued maturation of my interest in the care of these challenging vascular patients. 

Posted January 2013

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