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Background: To review and describe the available literature on cost-utility analysis of revascularization and non-revascularization treatment approaches in chronic limb-threatening ischemia., Methods: A systematic review was performed on cost-utility analysis studies evaluating revascularization (open surgery or endovascular), major lower extremity amputation, or conservative management in adult chronic limb-threatening ischemia patients. Six bibliographic databases and online registries were searched for English language articles up to August 2021. The outcome for cost-utility analysis was quality-adjusted in life years. Procedures were compared using incremental cost-effectiveness ratios which were converted to 2021 United States dollars. Study reporting quality was assessed using the 2022 Consolidated Health Economic Evaluation Reporting Standards statement. The study was registered in International Prospective Register of Systematic Reviews (CRD42021273602)., Results: Three trial-based and five model-based studies were included for review. Studies met between 14/28 and 20/28 criteria of the Consolidated Health Economic Evaluation Reporting Standards CHEERS statement. Only one study was written according to standardized reporting guidelines. Most studies evaluated infrainguinal disease, and adopted a health care provider perspective. There was a large variation in the incremental cost-effectiveness ratios presented across studies. Open surgical revascularization (incremental cost-effectiveness ratios: $3,678, $58,828, and $72,937), endovascular revascularization (incremental cost-effectiveness ratios: $52,036, $125,329, and $149,123), and mixed open or endovascular revascularization (incremental cost-effectiveness ratio: $8,094) maybe more cost-effective than conservative management., Conclusions: The application of cost-utility analyses in chronic limb-threatening ischemia is in its infancy. Revascularization in infrainguinal disease may be favored over major lower extremity amputation or conservative management. However, data is inadequate to support recommendations for a specific treatment. This review identifies short and long-term considerations to address the current state of evidence. Cost-utility analysis is an important tool in healthcare policy and should be encouraged amongst the vascular surgical community., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Recommendations stated in the TASC II guidelines for the treatment of peripheral arterial disease (PAD) regard a heterogeneous group of patients ranging from claudicants to critical limb ischaemia (CLI) patients. However, specific considerations apply to CLI patients. An important problem regarding the majority of currently available literature that reports on revascularisation strategies for PAD is that it does not focus on CLI patients specifically and studies them as a minor part of the complete cohort. Besides the lack of data on CLI patients, studies use a variety of endpoints, and even similar endpoints are often differentially defined. These considerations result in the fact that most recommendations in this guideline are not of the highest recommendation grade. In the present chapter the treatment of CLI is not based on the TASC II classification of atherosclerotic lesions, since definitions of atherosclerotic lesions are changing along the fast development of endovascular techniques, and inter-individual differences in interpretation of the TASC classification are problematic. Therefore we propose a classification merely based on vascular area of the atherosclerotic disease and the lesion length, which is less complex and eases the interpretation. Lesions and their treatment are discussed from the aorta downwards to the infrapopliteal region. For a subset of lesions, surgical revascularisation is still the gold standard, such as in extensive aorto-iliac lesions, lesions of the common femoral artery and long lesions of the superficial femoral artery (>15 cm), especially when an applicable venous conduit is present, because of higher patency and limb salvage rates, even though the risk of complications is sometimes higher than for endovascular strategies. It is however more and more accepted that an endovascular first strategy is adapted in most iliac, superficial femoral, and in some infrapopliteal lesions. The newer endovascular techniques, i.e. drug-eluting stents and balloons, show promising results especially in infrapopliteal lesions. However, most of these results should still be confirmed in large RCTs focusing on CLI patients. At some point when there is no possibility of an endovascular nor a surgical procedure, some alternative non-reconstructive options have been proposed such as lumbar sympathectomy and spinal cord stimulation. But their effectiveness is limited especially when assessing the results on objective criteria. The additional value of cell-based therapies has still to be proven from large RCTs and should therefore still be confined to a research setting. Altogether this chapter summarises the best available evidence for the treatment of CLI, which is, from multiple perspectives, completely different from claudication. The latter also stresses the importance of well-designed RCTs focusing on CLI patients reporting standardised endpoints, both clinical as well as procedural., (Copyright © 2011 European Society for Vascular and Endovascular Surgery Urology. Published by Elsevier Ltd. All rights reserved.)

Structured follow-up after revascularisation for chronic critical limb ischaemia (CLI) aims at sustained treatment success and continued best patient care. Thereby, efforts need to address three fundamental domains: (A) best medical therapy, both to protect the arterial reconstruction locally and to reduce atherosclerotic burden systemically; (B) surveillance of the arterial reconstruction; and (C) timely initiation of repeat interventions. As most CLI patients are elderly and frail, sustained resolution of CLI and preserved ambulatory capacity may decide over independent living and overall prognosis. Despite this importance, previous guidelines have largely ignored follow-up after CLI; arguably because of a striking lack of evidence and because of a widespread assumption that, in the context of CLI, efficacy of initial revascularisation will determine prognosis during the short remaining life expectancy. This chapter of the current CLI guidelines aims to challenge this disposition and to recommend evidentially best clinical practice by critically appraising available evidence in all of the above domains, including antiplatelet and antithrombotic therapy, clinical surveillance, use of duplex ultrasound, and indications for and preferred type of repeat interventions for failing and failed reconstructions. However, as corresponding studies are rarely performed among CLI patients specifically, evidence has to be consulted that derives from expanded patient populations. Therefore, most recommendations are based on extrapolations or subgroup analyses, which leads to an almost systematic degradation of their strength. Endovascular reconstruction and surgical bypass are considered separately, as are specific contexts such as diabetes or renal failure; and critical issues are highlighted throughout to inform future studies., (Copyright © 2011 European Society for Vascular and Endovascular Surgery Urology. Published by Elsevier Ltd. All rights reserved.)

Critical limb ischaemia (CLI) is a particularly severe manifestation of lower limb atherosclerosis posing a major threat to both limb and life of affected patients. Besides arterial revascularisation, risk-factor modification and administration of antiplatelet therapy is a major goal in the treatment of CLI patients. Key elements of cardiovascular risk management are smoking cessation and treatment of hyperlipidaemia with dietary modification or statins. Moreover, arterial hypertension and diabetes mellitus should be adequately treated. In CLI patients not suitable for arterial revascularisation or subsequent to unsuccessful revascularisation, parenteral prostanoids may be considered. CLI patients undergoing surgical revascularisation should be treated with beta blockers. At present, neither gene nor stem-cell therapy can be recommended outside clinical trials. Of note, walking exercise is contraindicated in CLI patients due to the risk of worsening pre-existing or causing new ischaemic wounds. CLI patients are oftentimes medically frail and exhibit significant comorbidities. Co-existing coronary heart and carotid as well as renal artery disease should be managed according to current guidelines. Considering the above-mentioned treatment goals, interdisciplinary treatment approaches for CLI patients are warranted. Aim of the present manuscript is to discuss currently existing evidence for both the management of cardiovascular risk factors and treatment of co-existing disease and to deduct specific treatment recommendations., (Copyright © 2011 European Society for Vascular and Endovascular Surgery Urology. Published by Elsevier Ltd. All rights reserved.)

The concept of chronic critical limb ischaemia (CLI) emerged late in the history of peripheral arterial occlusive disease (PAOD). The historical background and changing definitions of CLI over the last decades are important to know in order to understand why epidemiologic data are so difficult to compare between articles and over time. The prevalence of CLI is probably very high and largely underestimated, and significant differences exist between population studies and clinical series. The extremely high costs associated with management of these patients make CLI a real public health issue for the future. In the era of emerging vascular surgery in the 1950s, the initial classification of PAOD by Fontaine, with stages III and IV corresponding to CLI, was based only on clinical symptoms. Later, with increasing access to non-invasive haemodynamic measurements (ankle pressure, toe pressure), the need to prove a causal relationship between PAOD and clinical findings suggestive of CLI became a real concern, and the Rutherford classification published in 1986 included objective haemodynamic criteria. The first consensus document on CLI was published in 1991 and included clinical criteria associated with ankle and toe pressure and transcutaneous oxygen pressure (TcPO(2)) cut-off levels <50 mmHg, <30 mmHg and <10 mmHg respectively). This rigorous definition reflects an arterial insufficiency that is so severe as to cause microcirculatory changes and compromise tissue integrity, with a high rate of major amputation and mortality. The TASC I consensus document published in 2000 used less severe pressure cut-offs (≤ 50-70 mmHg, ≤ 30-50 mmHg and ≤ 30-50 mmHg respectively). The thresholds for toe pressure and especially TcPO(2) (which will be also included in TASC II consensus document) are however just below the lower limit of normality. It is therefore easy to infer that patients qualifying as CLI based on TASC criteria can suffer from far less severe disease than those qualifying as CLI in the initial 1991 consensus document. Furthermore, inclusion criteria of many recent interventional studies have even shifted further from the efforts of definition standardisation with objective criteria, by including patients as CLI based merely on Fontaine classification (stage III and IV) without haemodynamic criteria. The differences in the natural history of patients with CLI, including prognosis of the limb and the patient, are thus difficult to compare between studies in this context. Overall, CLI as defined by clinical and haemodynamic criteria remains a severe condition with poor prognosis, high medical costs and a major impact in terms of public health and patients' loss of functional capacity. The major progresses in best medical therapy of arterial disease and revascularisation procedures will certainly improve the outcome of CLI patients. In the future, an effort to apply a standardised definition with clinical and objective haemodynamic criteria will be needed to better demonstrate and compare the advances in management of these patients., (Copyright © 2011 European Society for Vascular and Endovascular Surgery Urology. Published by Elsevier Ltd. All rights reserved.)

Non-invasive vascular studies can provide crucial information on the presence, location, and severity of critical limb ischaemia (CLI), as well as the initial assessment or treatment planning. Ankle-brachial index with Doppler ultrasound, despite limitations in diabetic and end-stage renal failure patients, is the first-line evaluation of CLI. In this group of patients, toe-brachial index measurement may better establish the diagnosis. Other non-invasive measurements, such as segmental limb pressure, continuous-wave Doppler analysis and pulse volume recording, are of limited accuracy. Transcutaneous oxygen pressure (TcPO(2)) measurement may be of value when rest pain and ulcerations of the foot are present. Duplex ultrasound is the most important non-invasive tool in CLI patients combining haemodynamic evaluation with imaging modality. Computed tomography angiography (CTA) and magnetic resonance angiography (MRA) are the next imaging studies in the algorithm for CLI. Both CTA and MRA have been proven effective in aiding the decision-making of clinicians and accurate planning of intervention. The data acquired with CTA and MRA can be manipulated in a multiplanar and 3D fashion and can offer exquisite detail. CTA results are generally equivalent to MRA, and both compare favourably with contrast angiography. The individual use of different imaging modalities depends on local availability, experience, and costs. Contrast angiography represents the gold standard, provides detailed information about arterial anatomy, and is recommended when revascularisation is needed., (Copyright © 2011 European Society for Vascular and Endovascular Surgery Urology. Published by Elsevier Ltd. All rights reserved.)

Peripheral arterial disease is commonly caused by atherosclerosis, and symptoms depend on the location and size of the affected artery, metabolic demands on the tissue, and the presence or absence of a collateral circulation. This article reviews the current evidence for the diagnosis and management of peripheral arterial disease.

Aim: Cilostazol is a phosphodiesterase III inhibitor with a firm evidence base for use in intermittent claudication. We aimed to assess outcomes using cilostazol in critical limb ischemia (CLI)., Methods: Prospective consecutive observational study of local practice. Twenty-three patients (26 lower limbs) with CLI defined by the TASC II Inter-Society Consensus for the Management of Peripheral Arterial Disease. None were considered suitable for radiological or surgical revascularisation. Oral cilostazol starting at 100 mg twice daily was used in combination with best medical therapy (BMT)., Results: Mean follow-up time was 13.7 months (median 11.8 months). One patient died (5% of patients). There was one major amputation (4% of limbs). Six limbs (26%) improved, 5 reverting to a diagnosis of intermittent claudication and 1 becoming asymptomatic. The remaining 15 limbs remained ischemic, with some clinical improvement and without major amputation., Conclusions: In this study, there was one major amputation and one death in a mean period of a year following a diagnosis of non-reconstructible limb ischemia. The use of cilostazol was associated with marked improvement in 26%, and may have at least deferred major amputation in those with ongoing ischaemia. Further study using cilostazol in this context is recommended.

Objective: The aim of this study was to assess the efficacy and durability of infra-inguinal PTA in patients with CLI, in terms of clinical outcome., Design: Retrospective study of 50 consecutive patients with CLI that were exclusively treated by infra-inguinal PTA., Methods: The indications for intervention were rest pain in seven (14%) patients, non-healing ulcers in 27 (54%), and gangrenous lesions in 16 (32%). Thirty-three (66%) of these patients presented with a single arterial lesion, and the remaining 17 (34%) with multilevel arterial lesions. Kaplan-Meier analysis was used to assess survival, patency, limb-salvage rates, and amputation-free survival., Results: A total of 67 endovascular procedures were performed and 59 (88.1%) of them were considered to be technically successful. The median follow-up period was 12 months (interquartile range: 17 months). The 30-day mortality was 4%, while the cumulative survival rates at 12, 24, and 36 months were 73%, 67%, and 59%, respectively. The cumulative primary patency rates at 12 and 24 months were 63% and 52%, respectively, and remained unchanged thereafter. The estimated secondary patency rate was 72% at 36 months. There was only one below-knee amputation in the patients that were treated exclusively with infra-inguinal PTA. The cumulative amputation-free survival at the same period was estimated at 60%., Conclusions: Infra-inguinal PTA had a good early and late outcome in this series of patients with a limited life expectancy. These results are comparable to historical results of surgical revascularization in the treatment of CLI. There is need for a randomized study to determine the primary optimal interventional approach for patients with CLI.

Objectives: historically infrainguinal reconstruction using heterogenous grafts has given poor results due to degradation and aneurysmal dilatation of the graft. A recently introduced heterogenous graft, the ProCol (bovine mesenteric vein) graft, may yield improved results. There are no published reports with respect to ProCol in infrainguinal reconstruction and hence we have reviewed our initial experience with this graft., Methods: retrospective analysis of six patients in whom infrainguinal reconstruction with ProCol was undertaken between March and August 2001., Results: the primary patency rate was 0% at 3 months, with grafts failing between 4 and 113 days. Two grafts underwent aneurysmal dilatation., Conclusion: we are unable to recommend use of the ProCol graft in infrainguinal reconstruction.

Objectives: To compare the outcome of exercise therapy or angioplasty for the treatment of patients with intermittent claudication., Design: A summation analysis., Methods: A search using MEDLINE and PUBMED between 1966 and April 1999 followed by a review of the manuscripts yielded 54 studies involving angioplasty and 27 studies involving exercise therapy for intermittent claudication. Studies were only included (12 angioplasty and nine exercise series) when results were available for patients with intermittent claudication alone, and when outcome was assessed in terms of symptoms at a minimum of 6 months., Results: The total number of claudicants undergoing exercise therapy was 294 patients, with a mean symptomatic success rate of 38. 4% and a mean improvement in maximum walking distance of 189.7% at 6 months. The total number of claudicants undergoing angioplasty was 2071, with a mean overall symptomatic success rate of 76.6%. The mean overall complication rate was 9% and mean major complication rate was 2.7% for the angioplasty studies., Conclusion: Although the result demonstrates an advantage of angioplasty over exercise therapy at 6 months, there is a small risk of major complications. However, comparison of studies was impaired due to disparity in patient numbers, limited follow-up time and lack of uniformity in outcome assessment. In order to achieve a valid comparison of these therapies in a future randomised study, a validated disease-specific instrument for the assessment of symptomatic outcome for claudicants is required., (Copyright 2000 Harcourt Publishers Ltd.)

Objectives and Study Design: The diagnostic capability of angioscopy for endoluminal evaluation is established and its superiority over arteriography for completion studies has been confirmed. The therapeutic use of angioscopy in vein graft preparation is more controversial. The aim of this prospective study was to establish whether angioscopic vein preparation confers real benefits over existing techniques., Methods: Forty-seven patients were randomised to either full angioscopic (ANG) vein preparation (23 patients) or conventional (CON) in situ grafting (19 patients). All patients underwent completion studies with arteriography and angioscopy and postoperatively, entered a Duplex graft surveillance programme., Results: There was a significant difference in the incidence of wound morbidity: 26% in the ANG group as against 63% in the CON group (Fisher's exact test: p = 0.043), but no significant differences with respect to duration of operation, duration of vein graft preparation, length of hospital stay and both 30 day and 12 month secondary cumulative patencies (log rank test: p > 0.5). Completion angioscopy detected eight persistent valve cusps in six patients, all missed at arteriography, but failed to detect arteriovenous fistulae., Conclusions: Angioscopic preparation reduces wound morbidity and complements arteriography for detecting intraoperative defects. A large, prospective, randomised trial is now warranted to fully evaluate the potential therapeutic role of angioscopy with respect to current vascular practice.

The quality of distal run-off is one of the most important factors in determining outcome of femorodistal bypass. Accurate evaluation is important. Preoperative intra-arterial digital subtraction angiography and Doppler evaluation with pulse-generated augmentation of 90 patients who underwent femorodistal reconstruction were compared with postoperative angiography. Underestimation of distal run-off of the calf vessels occurred in 33% of cases by preoperative intra-arterial digital subtraction angiography. A below-knee pulse-generated run-off score of 3 or less was associated with a 12-month cumulative patency of 73% compared with 85% with a below-knee pulse-generated run-off score of 4 or more (P=0.079, log rank test; P =0.060, Wilcoxon signed rank test). The 12-month cumulative patency for grafts with a complete, incomplete and occluded arch as defined by pulse-generated run-off was 78, 90 and 38% respectively (P<0.0001 log rank and Wilcoxon signed rank tests). Preoperative evaluation of distal run-off before femorodistal bypass should not be based exclusively on intra-arterial digital subtraction angiography.

In patients with an acutely ischaemic limb a number of important decisions, in terms of both diagnosis and treatment, must be made. This article aims to guide the reader to the correct diagnosis and to explain the appropriate management options. Some newer techniques of intervention are introduced.

Pulse-generated run-off (PGR) is an established technique in the assessment of calf vessel patency. Dependent Doppler ultrasonography is proposed as a fast and simple alternative. Twenty-six limbs with severe ischaemia were evaluated by PGR, dependent Doppler examination and intra-arterial digital subtraction angiography (DSA). PGR was performed and scored as previously described. Dependent Doppler ultrasonography was performed after 5 min of foot dependency and scored as for PGR. Angiograms were scored by an independent radiologist, who awarded 2 for a vessel widely patent to the ankle, 1 for a diseased vessel crossing the ankle and 0 if no vessel was visualized. Of 78 calf vessels evaluated, 59 (76 per cent) appeared patent on PGR and dependent Doppler examination but only 33 (42 per cent) appeared patent to the ankle with intra-arterial DSA. There was very good agreement between PGR and dependent Doppler for detection of patent calf vessels (kappa = 0.93). Doppler signals were biphasic in six calf vessels on dependency and in 22 vessels with PGR. PGR and dependent Doppler ultrasonography detected 26 vessels communicating with the pedal arch compared with seven detected angiographically. There was good agreement between PGR and dependent Doppler examination for diagnosis of the most suitable vessel for distal anastomosis (kappa = 0.80). The wide availability and simplicity of dependent Doppler ultrasonography mean that no patient with a critically ischaemic limb should be denied reconstructive surgery on the basis of angiographic findings alone.

The aetiology of vein graft stenosis is poorly understood. In a cohort of 88 patients, the mean internal diameter of the vein grafts that developed a stenosis was 3.7 (3.1-4.2) mm compared to 4.7 (4.4-5.0) mm in those that did not (p = 0.006). The mean lowest compliance value in the 11 patients who developed a stenosis was 0.1 (0.07-0.13) % per mmHg compared to 0.21 (0.19-0.23) % per mmHg in the rest (p < 0.001). The presence of vein incompetence, site of tributaries or valves and the degree of endothelial cell loss were not related to the development of vein graft stenoses. The presence of a macrophage infiltrate (p < 0.001), lymphocyte infiltrate (p < 0.025) and subendothelial smooth muscle cells (p < 0.05) were all significantly more common in those grafts that developed a stenosis. Vein quality is an important factor in the development of graft stenoses.

Various vein factors affect the outcome of femorodistal bypass using vein in the treatment of lower limb ischaemia. In this review, the effect of factors such as vein size, compliance and morphology are discussed.

The quality of distal run-off is one of the most important factors influencing the early outcome of femorodistal vein grafting. During femoropopliteal and infrapopliteal bypass, assessment of graft resistance and flow were made using a combination of Doppler flowmeter recordings and measurements of arterial pressure. In a series of 100 reconstructions there were 12 early failures. The mean (95 per cent confidence interval (c.i.)) maximal flow measurement in the group of grafts that failed when anastomosed to the popliteal artery or tibioperoneal trunk was 125 (74-176) ml/min compared with 256 (223-289) ml/min in successful grafts (P = 0.006). The corresponding figures for grafts inserted into a single crural vessel were 99 (72-126) and 165 (137-193) ml/min (P < 0.02). In the group that failed the mean (95 per cent c.i.) resistance after papaverine injection was 1.02 (0.82-1.22) peripheral resistance units (p.r.u.) compared with 0.47 (0.44-0.51) p.r.u. in the successful group (P < 0.001). Using a combination of resistance > 0.9 p.r.u. and capacity loss ratio after papaverine injection < 10 per cent to identify grafts that subsequently failed, the sensitivity, specificity, positive predictive value, negative predictive value and accuracy were 92, 97, 85, 99 and 97 per cent respectively. These results confirm that haemodynamic measurements can be used at operation to identify a group of patients in whom bypass is likely to fail.

Fifty patients who have undergone femorodistal bypass surgery have been followed up using impedance analysis and colour Duplex, with biplanar intraarterial digital subtraction angiography being used as the arbiter to define "at risk" grafts. An impedance score of 0.49 (0.43-0.55) was found in the "at risk" grafts, all of which underwent an interventional procedure compared to 0.39 (0.36-0.42) (p = 0.003, Mann-Whitney U test) in those with no problem. In total, 166 examinations were performed. The sensitivity and specificity were all greater than 91% when compared to angiography. Impedance analysis is simple, non-invasive, easy to perform and it takes only 10 min to complete the examination. In view of the results obtained using impedance analysis in comparison with Duplex scanning, we suggest that non-invasive impedance is a suitable alternative to colour Duplex for graft surveillance (mean +95% confidence interval).

Data was reviewed on patients presenting with lower limb-threatening ischaemia to a single vascular unit between September 1984 and December 1990. Three hundred and thirty patients underwent either femoro-popliteal or femoro-infrapopliteal reconstructive surgery and 316 primary amputations were performed on 281 patients. Sixty-three secondary amputations were performed following a femoro-distal bypass failure. The below-knee amputation to above-knee amputation ratio (BKA/AKA) was 1.0 in the primary amputation group to 0.91 in the secondary amputation group. A direct comparison cannot be made as the patients represent two separate clinical groups. The ratio of reconstructive operations to primary amputations more than doubled between the first and second halves of the study. The BKA:AKA ratio in the secondary amputation group and the total number of secondary amputations remained relatively constant. This study supports the view that previous femoro-distal surgery does not adversely affect the overall outcome of amputation.

Angioplasty is an important tool in the armamentarium of the clinician dealing with atherosclerotic disease. Diabetic patients with occlusive disease pose special problems. Four hundred and twenty-five lesions were dilated in 370 patients. No difference in site was found when comparing the diabetic and non-diabetic groups (p less than 0.001), but a significant difference in indication for treatment was observed. Cumulative patency at 5 years for iliac lesions in non-diabetic patients was 61.2% and in diabetic patients was 35.6% (p less than 0.05), for superficial femoral and popliteal artery lesions in non-diabetic patients it was 49.7% and in diabetic patients it was 38.8% (NS). The need for subsequent surgical intervention (p less than 0.01) and risk of death (p less than 0.001) are both significantly greater in the diabetic group. This study shows that angioplasty is a technique that can be used with success in diabetic patients and if the indications for interventions are compared, diabetic patients do not worse.

In 30 patients undergoing femoro-distal bypass the effect of papaverine and praxilene on blood flow in the graft was measured. The mean resting flow was 129 ml min-1 (range: 91-167) and after papaverine was 202 ml min-1 (142-262) and after praxilene was 205 ml min-1 (143-267). Praxilene has a similar effect to papaverine in the augmentation of blood flow, and further investigation is needed to see if long-term praxilene administration might improve graft survival.

Mortality rates after femoral embolectomy (FE) in patients with an acutely ischaemic leg vary from 20-40%. In the last 3 years we have adopted a policy of proceeding directly to femoral embolectomy in those patients with a strong clinical suspicion of an embolus. Where doubt exists about the diagnosis, arteriography is performed in combination with local streptokinase, balloon dilatation and/or reconstruction. In a prospective study between September 1984 and March 1987, 43 patients underwent femoral embolectomy with a limb salvage rate of 87%. The early mortality (within 30 days) was 16%, the late mortality was 26%, with a mean follow-up of 22 months. Of the seven patients who died within 30 days, one had a successful embolectomy but died from a cerebrovascular accident. The remaining six failed to improve clinically, all had poor backbleeding and no return of the peripheral pulses. None of these patients had an amputation. We recommend that femoral embolectomy be performed in those patients with a short history of ischaemia (less than 72 h), a risk factor suggesting an embolic source and no past history of intermittent claudication. If all three criteria are not met, arteriography should be performed with a view to fibrinolytic therapy or vascular reconstruction. In those patients who have had a failed embolectomy or where the circulation cannot be restored promptly, despite fibrinolytic therapy and/or distal reconstruction, early major amputation may be life-saving.