Acute limb ischemia is a surgical emergency as a delay in reperfusion is associated with a high risk of irreversible tissue infarction potentially leading to limb loss and death. However, in medically compromised patients, perioperative morbidity and mortality remain high. An elderly woman with multiple comorbidities developed acute bilateral lower limb ischemia and was not felt to have a surgical revascularization option. Percutaneous restoration of reperfusion was successfully achieved by obtaining bilateral antegrade femoral arterial access followed by local infusion of fibrinolytic therapy and adjunctive thrombectomy resulting in bilateral lower extremity salvage.