Mechanical thrombectomy in acute lower limb ischaemia: beyond clot removal in an interventional radiology-oriented narrative review

BACKGROUND: Acute lower limb ischaemia (ALI) remains a time-critical vascular emergency associated with substantial risks of major amputation and early mortality. As contemporary interventional radiology increasingly incorporates aspiration, rotational, and pharmacomechanical thrombectomy, the key question is no longer whether mechanical thrombectomy (MT) can restore conduit flow, but how it should be positioned relative to catheter-directed thrombolysis (CDT), surgery, and hybrid therapy. CONCLUSIONS: This interventional radiology-oriented narrative review synthesizes current evidence on clinical staging, treatment selection, device classes, culprit-lesion management, post-revascularization antithrombotic treatment, and distal perfusion reassessment in ALI. Current data support MT as an important option, but not as a proven replacement for CDT or surgery. The main practical message is that successful ALI treatment requires more than clot removal: it requires correct staging, treatment of the lesion behind the thrombus, an individualized medical plan after revascularization, and recognition that limb salvage ultimately depends on restored tissue perfusion rather than conduit patency alone. Distal perfusion reassessment after thrombectomy and computed tomography angiography (CTA)-based planning are discussed as structured descriptive frameworks for reporting and future study rather than as validated algorithms.