Restoration of arterial blood flow to severely and acutely ischemic extremities results in tissue necrosis and systemic-metabolic complications associated with multiorgan failure and death. Surgical revascularization alone (SRA) was compared with revascularization and controlled reperfusion using standard cardiopulmonary bypass (R-CPB) in 41 patients with acute lower limb ischemia and ischemia-induced neurological dysfunction. The mean ischemia time was 17 ± 10 hours. Eighteen patients (44%) had unilateral femoral artery occlusion, 23 (56%) had distal aortic occlusion. Eleven patients (27%) presented ischemia-induced paraplegia. SRA was performed in 23 patients (56%), and R-CPB in 18 (44%). End-points were hospital mortality, lower limb amputation, the number of surgical fasciotomies, and the incidence of permanent neurological morbidity. Hospital mortality was 19.5%; it was 33% after SRA, and 5.5% with R-CPB (p = 0.007). R-CBP was superior to SRA in terms of amputation rate (0% vs. 21.7%, p = 0.056), number of fasciotomies performed (7% vs. 64%, p = 0.002), and neurological recovery (86% vs. 19%, p = 0.000). After acute lower limb ischemia controlled reperfusion using standard cardiopulmonary bypass techniques preserves skeletal muscle and nerve function and prevents local as well as systemic complications of postischemic restoration of bloodflow.