Two hundred seventy-five lower extremity amputations were performed over a 4-year interval for end-stage peripheral vascular disease. Fourteen patients (8.5%) of a total of 165 patients undergoing above-knee amputation (AKA) either suffered acute gangrenous ischemia of the AKA stump postoperatively, or were thought to be at high risk for same, and therefore underwent prophylactic inflow revascularization prior to or concomitant with AKA. The overall operative mortality rate was 28.5% in these 14 patients and was related either to inability to revascularize (two of three patients) or to the attempt to revascularize in the presence of a frankly necrotic amputation stump (three of five patients). Lower extremity amputation may be performed with an overall acceptably low mortality rate, which for our series is 0.9% for 113 below-knee amputation (BKA) and 2.8% for 140 AKA levels. Acute postoperative gangrene of the stump carries a high mortality rate and may be prevented by inflow revascularization prior to amputation. Three situations were identified as carrying a high risk for the subsequent development of gangrene: acute thrombosis of a prior combined inflow/outflow procedure, occlusion of the superficial femoral artery with an occluded/stenotic deep femoral artery and no palpable femoral pulse, and flat pulse volume recordings at the high thigh level. Patients who present for AKA with one of these indications should be considered as a candidate for prophylactic inflow revascularization prior to AKA to prevent ascending gangrene.