A 35-year-old endurance athlete was referred for unexplained claudication-like complaints in his left lower limb. Elsewhere he was treated for functional compartment syndrome and operated for popliteal artery entrapment syndrome which proved unsuccessful. He complained of a painful and swollen left thigh at maximal exercise. Clinical investigation, ankle-to-brachial indices at rest and an additional magnetic resonance angiography were normal. An incremental treadmill test showed pathological ankle-to-brachial pressure measurement, duplex ultrasound imaging confirmed flow limitation and showed lesions of endofibrosis in the left external iliac artery. Surgery consisted of performing an endarterectomy of the
external iliac artery with venous patching.