The paper by van Hooff et al. presents longer term follow-up on a large number of patients with iliac endofibrosis who have undergone operative repair with endarterectomy and patching (excluding those treated only for a kink, which they have previously published). The results after a median of 11 years are excellent, with overall operative satisfaction at 91.7% and 94.5% continued symptom reduction. This outcome is even more encouraging than the numbers suggest, because these patients are involved in very high levels of athletic performance. Although prior reports have described some intermediate-term results, these new data are compelling.

In addition to patient satisfaction, the authors provide evidence of the longer term durability of autogenous saphenous vein patches for these reconstructions. This is of great importance for patches under tremendous hemodynamic forces. Even longer periods of follow-up are required before there are definitive data on the best material for patches in this setting.

The authors performed an extensive operation, with retroperitoneal and femoral incisions, dividing and exteriorizing the external iliac artery through the groin, endarterectomy with a patch, and re-anastomosing the repaired vessel (with shortening if needed). Although useful for disease extending beyond the inguinal ligament, most cases can be done without a groin incision or dividing the external iliac artery, unless vessel shortening is required. This technique seems overly complex with the potential for complications. The key to successful treatment would seem to be identifying the particular variant presenting correctly—redundancy, kinking, fibrosis, or a combination of these—and to ensure that the issues are addressed. One should also be mindful of associated thromboembolic complications and arterial dissections.

This excellent report adds to a growing body of literature on diagnostic techniques, treatment strategies, and outcome data for iliac endofibrosis and provides strong evidence for the effectiveness, safety, and longer term outcomes of interventions for this disease. It is important to consider the young ages of these patients, and certainly longer term follow-up will be needed, because many decades of durability are required of these repairs.