Purpose: To examine the efficacy, safety, and procedural costs of percutaneous aspiration thrombectomy (PAT) as a first-line treatment for noniatrogenic acute lower limb ischemia (ALI) compared with conventional catheter-directed thrombolysis (CDT). Materials and Methods: All patients who underwent endovascular intervention for ALI from January 2015 to August 2017 were included. Fifteen patients were treated with the use of primary PAT and 27 patients were treated with the use of primary CDT. The primary end point was complete thrombus clearance with improvement in Thrombolysis in Myocardial Infarction (TIMI) score. Adjunctive treatment for thrombus removal was considered to indicate technical failure. Treatment of underlying chronic disease was not considered to indicate technical failure. Procedural costs for each patient were calculated by itemizing all disposable equipment, facility overheads, and staff costs. Results: Of the 15 primary PAT patients, technical success was achieved in 8 (53%); the remaining 7 (47%) required adjunctive CDT. Of the 27 primary CDT patients, technical success was achieved in 25 (89%); the remaining 2 (11%) required adjunctive PAT. There were 4 complications in the primary PAT group: 2 were procedure related and of a minor grade. There were 8 complications in the primary CDT group: All were procedure-related, including 2 major groin/retroperitoneal hemorrhage and 1 death from intracranial hemorrhage. Limb salvage was attained in all patients. There were no significant differences in average procedural costs per patient between the 2 groups. Conclusions: First-line use of PAT for endovascular treatment of ALI can reduce the need for CDT, with no significant cost difference.