Thrombolytic agents have been used to treat acute occlusion for almost 40 years. Local intra-arterial thrombolytic therapy (TT) is an effective treatment for acute arterial occlusion of a limb. A major potential benefit of TT is that limb ischemia can be managed with less invasive interventions. Aim :The present study aims at assessing the efficacy of intra-arterial catheter directed high dose streptokinase (SK) infusion in the management of acute thrombotic limb ischemia. Efficiency of the guide wire traversal test in predicting the initial success of thrombolysis and recanalization. Patients and Methods: Twenty patients (pts.) were included in the study (11 males, 9 females, and mean age 55.35). All pts had total arterial occlusion. Hypertension, coronary heart disease, diabetes mellitus, dyslipedemia, and smoking were present in 10, 7,8,12 and 10 pts. Respectively. Sites of occlusion were iliac in 2 pts., femoral in 10 pts., popliteal in 5 pts., tibial in one pt. and brachial in 2 pts. Angiography was used to assess the degree and site of occlusion. A guidewire was passed through the length of the occlusion. A bolus dose of 250,000 units of SK was given locally intra-arterial followed by 100, 000 units per hour locally intra-arterial. Infusions were limited to a period of 48 hours and re-assessed angiographically after 6 hours. Results: The outcome was complete lysis in 13 pts. (65%), partial lysis in 2 pts. (10%) and no lysis in 3 pts. (15%). Despite the local infusion of SK proximal to the arterial obstruction at high dosages, hypofibrinogenemia (less than 120 mg/dl) occurred in nine pts. (seven of them developed a bleeding complication). The Complications were infrequent, but included death in two pts. (10%) haematemesis in three pts. (15%) and local hematomas in four pts. (20%). Gender, dyslipedemia, hypertension did not affect the outcome, while old age (p-value 0.035), diabetes mellitus (p-value 0.035),smoking (p-value 0.009)and myocardial ischemia (p-value 0.015) were related to failure of TT. Passage of the Guidewire predicted success compared to failure of TT (p-value 0.005).Outcome of thrombolysis was also dependent on delay till intervention (p<0.001). Conclusion: Intra-arterial thrombolytic therapy for treatment of acute limb ischemia is effective treatment with a high success rate. Advancing age, smoking and diabetes mellitus were related to failure of thrombolytic therapy for acute limb ischemia. Guide-wire passage predicted success of catheter directed TT. The ability to achieve effective thrombolysis was influenced by the duration of the occlusion before the initiation of therapy. Intra-arterial SK produced major benefit with low morbidity and had a role in acute limb ischemia in particular selected patients depending on the degree of ischemia and the associated medical disease.