The Authors review 86 cases, aged over 70, needing surgical treatment because of atherosclerotic obstructive disease of the lower limb, stage III-IV. 35 patients underwent thigh amputation with 14% mortality in the early post-operative period (30 days) and 32% in the late post-operative period, considered up to 6 months. For 38 patients who underwent a revascularisation procedure mortality resulted 8% in the 30 post-operative days and 10% at 6 months. Escluding the aorto-iliac reconstructions through a trans-peritoneal approach, the overall mortality is limited to 3,2%. A major amputation was avoided in 76% of patients who underwent a revascularisation. On the base of their results the Authors discuss the indications of direct surgery in treatment of advanced ischemic lesions in elderly patients concluding that a surgical correction should be always considered in the aim of avoiding or limiting the amputation. In these high-risk elderly patients the extra-peritoneal aorto-iliac reconstructive technique must be preferred together with extraanatomical femoro-femoral or axillo-femoral by-passes.