Volume 50, Issue 1 Spring 2026 JVU 501-30 | CASE STUDY: Assisting in the Diagnosis of Endofibrosis in Young Adult Utilizing Indirect and Direct Arterial Physiologic Testing-CASE STUDY: Assisting in the Diagnosis of Endofibrosis in Young Adult Utilizing Indirect and Direct Arterial Physiologic Testing

CASE STUDY: Assisting in the Diagnosis of Endofibrosis in Young Adult Utilizing Indirect and Direct Arterial Physiologic Testing

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This 2026 case report in the Journal for Vascular Ultrasound describes the diagnosis and management of endofibrosis in a 41-year-old female elite cyclist and runner experiencing progressive right thigh pain during intense exercise. Endofibrosis is a rare vascular disorder predominantly seen in highly trained athletes, often affecting the external iliac artery, causing arterial stenosis and reduced blood flow that manifests as exercise-induced leg pain.<br /><br />The patient’s symptoms—exertional thigh pain relieved by rest—along with risk factors like a history of hyperlipidemia and prior smoking, prompted vascular evaluation. Initial indirect arterial testing revealed reduced ankle-brachial index (ABI) on the right side both at rest and post-exercise, with pulse volume recordings and Doppler findings consistent with external iliac artery occlusion. Duplex ultrasound and computed tomography angiography (CTA) confirmed occlusion of the right external iliac artery.<br /><br />Surgical thrombectomy with ilio-femoral bypass grafting restored perfusion, confirmed on follow-up testing. However, one year later, recurrent exercise-induced ABI drop and CTA revealed occlusion of the bypass graft, managed with percutaneous thrombectomy. Two years post-surgery, imaging showed patency of the graft despite symptom recurrence, although the exact cause remained unclear.<br /><br />The report discusses the pathophysiology of endofibrosis, attributed to repetitive mechanical stress on the external iliac artery due to hypertrophied hip flexor muscles and excessive vessel length, leading to intimal thickening and arterial narrowing. Diagnosis is challenging because patients typically appear healthy and asymptomatic at rest; therefore, exercise-provoked testing including ABI measurement and duplex ultrasound is vital. Treatment ranges from minimally invasive thrombectomy in early cases to bypass grafting for chronic occlusion.<br /><br />This case illustrates the importance of comprehensive clinical assessment, tailored physiologic testing, and vigilant follow-up for athletes with exertional leg pain. Early recognition of endofibrosis can prevent delays in diagnosis and guide appropriate intervention to restore limb perfusion and maintain athletic function.

Keywords

endofibrosis

external iliac artery occlusion

exercise-induced leg pain

ankle-brachial index

duplex ultrasound

computed tomography angiography

ilio-femoral bypass grafting

surgical thrombectomy

percutaneous thrombectomy

vascular disorder in athletes