Because a popliteal artery aneurysm (PAA) generates emboli that progressively deteriorate the distal arterial network, they can constitute limb-threatening lesions. In 20 to 40% of cases, discovery of PAA coincides with sudden occlusion and resulting acute ischemia. In 40 to 60% of these patients, surgical revascularization fails and amputation is required. The objective of this prospective study was to assess the value of intraarterial thrombolysis to restore distal runoff before surgical revascularization. Between January 1, 1992 and December 31, 1996, we treated 15 PAA causing acute ischemia in 15 male patients with a mean age of 66.7 years (range, 44 to 87 years). Diagnosis was documented by clinical examination and ultrasound imaging. Intraarterial thrombolysis was performed under arteriographic control through a multiperforated catheter inserted by the anterograde femoral route to the thrombus. After an initial bolus of 100,000 U of urokinase, 600,000 to 1,600,000 U was continuously infused over a period of 6 to 18 hr. Heparin sodium was administered throughout thrombolysis. Surgical revascularization was performed within 1 to 4 days (mean, 2 days) after thrombolysis by exclusion and bypass in 14 cases and percutaneous transluminal angioplasty with stenting in 1 case. The ensuing results showed that, if performed carefully, intraarterial thrombolysis can safely prepare patients presenting with occluded PAA with acute ischemia for surgical revascularization to restore distal runoff. We use this combined technique routinely in our department. Morbidity is low in comparison with the risks of amputation.