Intra-arterial thrombolysis should be the initial treatment of the acutely ischaemic lower limb.

We review and discuss the initial management of acute arterial occlusion. Thrombolytic therapy has been available for over 25 years but has failed to gain universal acceptance in the initial management of this condition. Support for the use of initial thrombolytic therapy in all patients is based on the following arguments. It may be difficult to distinguish clinically between an embolic or a thrombotic occlusion, and inappropriate surgery in the latter may have disastrous consequences. Therefore, arteriography should be performed in all patients. It is then easy to place a catheter for thrombolytic therapy. This therapy allows treatment of associated medical problems before definitive surgery, and it may enable a more accurate assessment of the obstruction and better planning of surgery after dissolution of some of the occluding thrombus. Recanalisation may make reconstructive surgery easier and, finally, the results with initial thrombolysis are better than with surgery alone. The case against the motion is that expeditious surgery is in the patient's best interest, particularly in embolus, and when there is ischaemic damage to the limb. Furthermore, the reports of thrombolysis currently available are uncontrolled and do not demonstrate convincingly that the results of thrombolytic therapy are superior to surgery alone.