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Over a 30-month period (May 1988 to November 1990) 143 acutely ischemic lower extremities (126 patients) were treated with an aggressive surgical approach that included ankle level tibial-peroneal artery thromboembolectomy. Twelve lower extremities in 10 patients that remained ischemic were further treated with adjuvant ankle level urokinase infusion. Sixteen ankle level arteries in 12 extremities were infused with an intraoperative bolus (1 to 2) of urokinase (50,000 to 100,000 units). Continuous postoperative urokinase (25,000 to 50,000 units per catheter per hour × 1 to 5 days) was infused through ankle level arteriotomies in 10 extremities (14 arteries) that did not improve with the initial intraoperative bolus. Concomitant bypass grafting was necessary in four extremities. With adequate inflow established, adjuvant ankle level urokinase salvaged all 12 extremities. The mean increase in ankle/brachial pressure index was 0.84. During continuous postoperative urokinase infusion, lower extremity bleeding requiring blood transfusion occurred in four patients (50%). No deaths occurred in the operative period. Although rhabdomyolysis occurred in 90% of patients, no patients had renal insufficiency. The addition of ankle level urokinase delivery increased the potential limb salvage from 90% of the entire 143 extremities treated during this period to an actual limb salvage of 98%. A mean follow up of 13 months (6 to 36 months) identified one late amputation. Despite the demanding postoperative management required in these patients and the frequent need for early reoperation, the limb salvage obtained justifies this aggressive adjuvant technique in the management of the acutely ischemic lower extremity. (J Vasc Surg 1992;15:771–9.)

In the classic subclavian steal syndrome, vertebrobasilar insufficiency is caused by reverse flow in the vertebral artery ipsilateral to a subclavian stenosis or occlusion. We present two patients with vertebrobasilar insufficiency and ipsilateral vertebral and subclavian occlusive disease. The postulated mechanism of vertebrobasilar insufficiency is reverse flow in collateral neck vessels. In both patients, symptoms were relieved by carotid subclavian bypass. Thus, vertebral occlusion ipsilateral to a subclavian stenosis does not preclude subclavian steal syndrome. (J VASC SURG 1985;2:913-6.)