Acute lower extremity ischemia (ALI) is a common vascular emergency.1 The etiology of ALI can be multifactorial, with thrombotic occlusion generally occurring in the setting of a previously treated arterial segment or associated with atherosclerotic arterial disease.2 Patients with hypercoagulable states are known to have a risk of native arterial thrombosis, one of the most challenging of ALI scenarios to treat.3 A recent analysis of a large database showed improved overall in-hospital mortality and early amputation rates. However, in the context of a hypercoagulable state, the surgical decisions and related clinical outcomes have been poorly reported.1