The choice of surgical intervention is influenced by both the clinical status of the patient and the etiology of the ALI.3 Although relatively uncommon, ALI secondary to native arterial thrombosis is an ominous form. Information about the outcomes for this group of patients has been scarce. O'Connell and Quiñones-Baldrich2 reported that patients with thrombotic, rather than embolic, occlusion had worse outcomes overall. In addition, Torrealba et al10 reported significantly worse outcome for patients with diagnosed hypercoagulable disorders. Successful revascularization was disappointingly low in patients with COVID-19 when compared with previously reported series.12 The high failure rate in our experience might have resulted from the two typical aspects observed in these patients. First, at completion angiography, we frequently found a situation of “desert foot” and a typical absence of the forefoot microcirculation, despite the removal of the thrombus with selective thrombectomy of the below-the-knee and ankle arteries. Second, this aspect might have led to sudden early recurrent thrombosis of the treated segment. The observation that a suspect marked hypercoagulability might be a contributory cause of technical failure might indirectly find support because a similar rate of success was obtain in those transferred from another hospital and the mean ischemia time was not significantly associated with technical failure. Both the inability to obtain effective distal revascularization and the recurrent episodes of thrombosis of the treated segments prompted us to change our treatment protocol by including a more aggressive regimen with thrombolysis and continuous infusion of heparin.