Objective To evaluate the safety and efficacy of continuous intravascular heparin infusion for acute lower extremity ischemia (ALI) in the elderly patients. Methods Sixty-seven elderly patients with ALI were enrolled in the study, who received endovascular treatment from July 2015 to February 2017 in PLA Army General Hospital. They were divided into 2 groups, one treated with standard catheter-directed thrombolysis (control group, n=35) and the other with continuous intraventricular heparin perfusion (heparin group, n=32). In the former, urokinase 1 million IU/day was administered via continuous infusion and low molecular heparin with 100 IU/(kg·12 h) hypodermically. In the latter, a continuous infusion heparin was administered at 18 U/(kg·h). Patients were followed up for 30 d, 3 months, and 1 year. Data of the general information, severity of ischemia, ankle brachial index (ABI), duration of the treatment, number of clots dissolved by thrombolysis and complications were recorded, and comparison was made between the 2 groups. SPSS statistics 23.0 was used for data analysis, and t test or Chi-square test for comparison, depending on data type. Results No significant difference was observed in general information and ischemic severity between the 2 groups (P>0.05). Compared with the control group, heparin group had significantly longer duration of continuous treatment [(53.24±10.49) vs (35.67±9.25)min, P=0.010] and lower hemorrhage rate [0.0%(0/32) vs 11.4%(4/35), P=0.001]. There was no significant differences in total thrombolysis rate, improvement in ABI, incidence of cardiovascular events, rate of amputation and mortality within 30 days, and rate of free-amputation at 1 year of follow-up (P＞0.05). Conclusion Continuous intravascular heparin infusion can achieve good short-term effects with significantly reduced hemorrhage rate. It serves as a safe and effective minimally invasive treatment for ALI in the elderly patients with high risk of hemorrhage.