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Objective:Contrast arteriography(CA) is considered to be the gold standard for preoperative and intraoperative imaging modality for patients with chronic lower limb ischemia.We have previously shown that high quality duplex arteriography can safely replace preoperative CA in these patients.Our experience with duplex guidance for infrainguinal arterial balloon angioplasties and stenting encouraged us to investigate whether this approach can also be used effectively in the setting of acute ischemia.Methods:27 high-risk patients with acute lower extremity ischemia were admitted to our institution with intention to perform endovascular interventions.Twelve patients(44%) had elevated serum creatinine(≥1.5 mg/dL) and one additional patient(4%) was allergic to iodine.Twelve patients(44%) had thromboembolic complications during duplex-guided balloon angioplasties (DGBA),11 patients (40%) had acute arterial thromboembolism,2 patients(8%) had thrombosed infrainguinal arterial bypasses with vein(femoral-anterior tibial and femoral-dorsalis pedis) and the remaining 2 patients(8%) had thrombosed popliteal aneurysms discovered on preoperative duplex scan.Five of 23 patients(22%) with arterial thromboembolism had previous ipsilateral balloon angioplasties and stenting procedures.Results:Of the 12 intraoperative DGBA complications,thromboemboli were diagnosed in the popliteal artery in 6 cases(50%), in the tibio-peroneal trunk in 5 cases(42%) and in the peroneal artery in the remaining case(8%).These were treated under duplex-guidance only with intraarterial instillation of thrombolytic agents in 5 cases(42%) and suction thrombectomy in the remaining 7 cases(58%).Of the 11 cases of acute arterial ischemia, the most proximal thrombus end was identified in the superficial femoral artery in 5 cases(45%) and in the popliteal artery in the remaining 6 cases(55%).Nine of these patients(82%) were treated with duplex-guided suction thrombectomy, balloon angioplasty and stenting. The remaining 2patients(18%) had a combination of Trellis® thrombectomy followed by suction thrombectomy, balloon angioplasty and stenting.Complete evacuation of the thrombus was achieved after overnight thrombolysis in 2 patients with arterial thromboembolism. Two thrombosed infrapopliteal bypasses were treated with suction thrombectomy and balloon angioplasty of multiple stenotic lesions.Both patients with thromboses popliteal aneurysms required suction thrombectomy, overnight thrombolysis and consecutive placement of Viabahn® stented grafts for aneurysm exclusion.Conclusions:Our initial experience suggests that patient with acute lower limb ischemia of diverse etiology can be safely and effectively treated by endovascular procedures under duplex guidance alone.