Background:
External iliac artery endofibrosis is a non-atherosclerotic disease. It affects young individuals, particularly cyclists.

Materials and Methods:
A systematic literature review was conducted to highlight the intriguing aspects of this pathology and a total of 493 patients were retrieved to whom we added two patients
treated at our institution.

Results: 434 (87%) of the patients were cyclists, 7 (3.6%) triathletes (practicing cycling, running, and swimming), (1.4%) runners, and 18 (8.2%) other. Both limbs were equally involved, and no dominant limb was noted. Twenty-four works and fifty-eight patients were analyzed; in 51.7% (n=30) of cases, the left lower limb was involved, and in 48.3% (n=28) of cases, the right lower limb was involved. The external iliac artery was involved in 90% of cases, however, 30 patients (10%) presented an unusual location, isolated or associated with the lesion beginning on the common iliac artery (5%) or extending to the femoral artery. In addition, the quadricipital artery and the profunda femoris artery can be affected, modifying the haemodynamic conclusions of the complementary examinations Professional cyclists who annually cover an average distance of 10,400 kilometres (range 4,200 min. - 27,500 max. kilometres) were preferentially affected. While the total mileage accumulated since the start of training is a factor that should be considered, we believe that the intensity of the training plays an even more crucial role in the development of the lesion. Noticeably, only 10 (2%) patients had specific atherosclerotic risk factors such as cigarette smoking or mild dyslipidemia. The main symptoms were buttock claudication and calf pain (37% and 30%, respectively). Historically angiography was the diagnostic method of choice in 53% of cases; however, in the recent decades CT and MRI were preferentially used. 71% of the patients were treated with endofibrosectomy, a patch was added in 13 (3%). An Iliofemoral bypass graft was performed in 29% of the patients. Five-year primary and secondary patency rates either for endofibrosectomy or bypass graft reached 90%.

Conclusions: Surgical treatment is the gold standard. Patients unwilling to undergo surgery may opt for less invasive treatments such as percutaneous transluminal angioplasty with stent positioning which seems however, to have suboptimal long-term results.