Acute thrombosis of a popliteal artery aneurysm (PAA) often results in critical limb ischemia of sudden onset, with a compromised, disastrous runoff, making direct revascularization hazardous. Pre-operative thrombolysis may simplify or even make arterial repair redundant by reopening crural arteries and restore the outflow. Systemic review was performed to study clinical outcome of both treatment modalities. A systemic review was conducted of data on thrombosed popliteal artery aneurysms in the English literature from 1990 using the Pubmed and MEDLINE electronic databases up to Jun 30rd 2008. The literature search identified no randomized trials, 8 prospective studies, and 25 retrospective studies on the management of acute thrombosed PAAs. These studies contained 895 patients presenting with acute ischemia. The mortality rate after surgical repair (recorded in 564 patients) for an acute PAA was 4%, with a range of 0% - 17%. In 17% (range, 0 - 38%) of the acute thrombosed PAAs an amputation within 30 days was necessary due to irreversible ischemia. Thrombolysis was used in 313 patients, with or without additional surgery. In 71% of these 313 patients, thrombolysis was successful, defined as restored outflow via at least one patent crural artery. Thrombolysis before surgery resulted in an absolute reduction of the number of amputations with 2.3% compared to surgery alone, but this effect is not statistically significant because of the high heterogenicity of the combined interventions. In 245 patients (139 patients without, 106 with pre-operative thrombolysis) patency rates of surgical bypass surgery were recorded. The mean primary patency rates at 1, 3 and 5 years of the bypasses in the “thrombolytic followed by surgery” group were 79% ± 19.0, 77% ± 6.3 and 74% ± 6.3 respectively. For the “surgery alone” group the patency rates were 71% ± 12.8, 54% ± 26.0 and 45% ± 28.4 respectively. Morbidity and mortality are high for the acute symptomatic PAA, with a mean 30-day amputation rate of 17%, and a mortality rate of 4%. Thrombolysis before surgery reduces amputation rate and increases primary patency rates of surgical interventions, however, these differences are not statistically significant.