In keeping with much of this edition of the Hand Clinics journal, this article accurately and appropriately sets out the background, epidemiology and current approach to management of acute and chronic upper limb ischaemia. The background sections ease the reader through a potentially broad topic with a well written narrative from expert authors. I felt it would have been helpful if the article had better addressed the key aim of comparing thrombolytics with alternative methods of management; instead it considered the pros and cons of thrombolytics as a treatment modality. Correctly acknowledging the lack of current high level evidence and indeed lack of comparable studies, the authors sadly fail to appropriately reference those studies which do exist and appear to undertake potentially confusing statistical analysis, specifically relating to complication rates. Using a combination of these findings and their own expert opinion the authors draw conclusions, which are logical, but in places lack evidential backing. In summary the review presents an engaging discussion of a topic which clearly needs substantial further investigation before any firm conclusions can be drawn. The authors’ opinion although prominent, does hold value and given the lack of higher powered evidence should not be underestimated.