Management of Acute Infrainguinal Graft Occlusion: Surgical and Endovascular Approaches in Contemporary Practice

Background: Acute infrainguinal bypass graft occlusion is a critical vascular emergency that threatens limb viability and challenges both surgical and endovascular management. Despite progress in revascularization strategies, outcomes remain suboptimal, and consensus on the optimal treatment approach is lacking. Methods: This narrative review summarizes current evidence on the epidemiology, etiology, diagnosis, and treatment of acute infrainguinal graft occlusion. Particular attention is given to the evolving role of catheter-directed thrombolysis and mechanical thrombectomy, as well as to prevention strategies based on structured surveillance and medical optimization. Results: Infrainguinal bypass failure is influenced by technical, anatomical, and systemic factors, with distinct mechanisms affecting vein and prosthetic grafts. While surgical thrombectomy remains a viable option in selected cases, endovascular techniques have gained prominence due to their minimally invasive nature and promising short-term outcomes. Prevention of occlusion through duplex surveillance and best medical therapy is crucial to preserving graft patency and reducing major amputation risk. Conclusions: Management of acute graft occlusion requires timely diagnosis and a tailored, multidisciplinary approach. Although endovascular therapies have expanded treatment options, further prospective studies are needed to define optimal strategies and improve long-term outcomes in this high-risk population.