A 48 year old long distance triathlete complained of exercise induced thigh pain on the left side for several years. Physical examination in the presence of strongly palpable foot pulses was uneventful at rest, but there was a drop in ankle brachial index (ABI) to 0.4 after exercise. Magnetic resonance angiography (MRA) revealed a mild stenosis of the external iliac artery (EIA) on the left side (A). Through extraperitoneal access, a high grade stenosis became apparent (B). After vein patch plasty and an uneventful post-operative recovery, the athlete was able to increase training intensity free of pain.