Acute Limb ischaemia presents dramatically with excruciating pain in the affected limb. The incidence appears to be increasing probably due to an increase in the age of the population, and the most common age at presentation is 70–80 years. Trauma, embolism and acute thrombosis are the three leading causes of acute limb ischaemia. Occlusions of arterial bypass grafts (synthetic or venous)—performed at an earlier occasion for chronic occlusive peripheral arterial disease (PAD)—have emerged as a common cause of acute limb ischemia in the West. The seven P’s summarize the cardinal features of acute limb ischaemia, pain, pallor, pulselessness, paraesthesia, paresis, poikilothermia (cold limb), perished. Examination is directed towards detecting disorders of heart rate and rhythm (irregular pulse), presence of murmurs, cardiomegaly, raised JVP, edema and BP. Peripheral pulses should be carefully palpated. Sign of chronic ischaemia should be looked for; their presence indicates acute thrombosis in a pre-existing stenotic lesion in the artery. Aneurysms, specially abdominal and popliteal should be excluded by careful palpation. Arteries should be auscultated for bruits. Portable Doppler is used to detect an audible signal over the affected artery and to measure the pressure in the affected vessels. Class I: Viable limb, Class II: Threatened, Class III: Irreversible ischaemia. Acute limb ischaemia is a surgical emergency. Early definitive treatment is of paramount importance as irreversible ischaemia leading to limb loss results in the absence of the same. In native arterial occlusion (embolism), the “golden period” for limb revascularization is 6–8 hours from the onset of symptoms. Limb revascularization should not be attempted in Class III ischemia, and primary amputation is the best option in these advanced cases). Adequate analgesia, intravenous fluids, and broad-spectrum antibiotics should be administered. There is some evidence that mannitol reduces renal damage associated with revascularization. Limb circulation may be restored either by emergency embolectomy, intra-arterial thrombolytic therapy, or by employing mechanical thrombectomy devices. If a diagnosis of embolism can be confidently made, then embolectomy is the treatment of choice. Several percutaneous mechanical thrombectomy (PMT) devices are commercially available. These devices either employ ‘aspiration’, ‘microfragmentation’ for thrombus removal.