The purpose of this study was to evaluate the efficacy of direct intra-arterial Urokinase infusions prior to anticipated adjunctive reconstructive vascular procedures in 16 patients with 24 acutely or subacutely occluded lower extremity grafts (22 femoropopliteal, 2 femorotibial). Complete thrombolysis was achieved angiographically in 18 (75%) of 24 graft occlusions. Neither age, gender, current smoking, diabetes mellitus, hypertension, nor coronary arterial disease were significantly associated with complete thrombolysis. The only significant factor related to complete thrombolysis was the duration of the occlusion prior to lytic treatment (p < 0.05). Adjunctive reconstructive procedures were performed for eleven of 18 cases in which complete thrombolysis was achieved. These included nine percutaneous transluminal balloon angioplasties (at eight distal and one proximal anastomotic stenoses) and two bypass operations (femoropopliteal). The remaining seven cases had no adjunctive procedure. These 18 cases were examined for patency rates during nine months of follow-up. Six (54%) of 11 cases with adjunctive reconstructive vascular procedures remained patent, while one (14%) of seven cases with no adjunctive procedure remained patent (p = 0.1). Six (25%) of 24 cases resulted in incomplete thrombolysis. Vascular procedures following these cases included two bypass operations, three amputations and one sympathectomy. This study suggests that complete thrombolysis of acutely occluded grafts might have minimized subsequent reconstructive procedures. Identification of correctable lesions and adjunctive reconstructive procedures performed following complete thrombolysis may be the important factors related to long-term patency.