Background: The incidence of CLI is estimated at 1% of the population aged 50 years and older and at approximately double that rate in the over-70 age group. These frequencies are expected to increase significantly with the aging population and the expected increase in diabetes. Within 1 year of being diagnosed with CLI, 40% to 50% of diabetics will experience an amputation, and 20% to 25% will die. Aim of the Work: Is to discuss whether patients with CLI due to TASC D lesion will still best managed with femoropopliteal bypass or can be managed by balloon angioplasty that much decreases postoperative morbidities especially with appearance of new advances in endovascular techniques. Patients and Methods: This was a prospective randomized comparative study, including 30 patients that attended outpatient clinic in Ain Shams University Hospital and Nasser Institute Hospital. The patients were divided into two groups: Group "A" include 15 patients (from1 to 15) underwent bypass surgery and Group "B" include 15 patients (from 16 to 30) underwent balloon angioplasty. Results: The ages of patients ranged from 60:70 years old with mean age 65+ 5 Years. In group (A) ABI of the 15 patients increased more than 0.3 postoperative while in group (B) ABI of 9 patients increased more than 0.3 while ABI of 3 patients showed minimal increase less than 0.3 (and they clinically failed) after exclusion of technical failure group. As regard to poatency in group (A), primary and secondary patency at 3rd and 6th month was 100% while in group (B), our three and six months primary patency results were 66.6% and 62.6% respectively while secondary patency was 88.8% and 87.5% at 3rd and 6th month respectively. In group (A), No patients underwent major amputation until the 3rd month while in group (B), one patient underwent below knee amputation at the 3rd month. Conclusion: The overall recommendation is that severe limb ischemia patients with long life expectancy and useable great saphenous vein, should usually have bypass surgery first. This is because that saphenous vein bypass surgery has long-term patency results and associates with significant improved amputation free survival. The rate of balloon angioplasty failure is high, and results of bypass surgery after failed balloon angioplasty are significantly worse than for primary bypass surgery. However, patients with short life expectancy (as those who are old aged with multiple comorbidities such as cardiovascular diseases) and those without a useable vein, should usually have balloon angioplasty first because they will not survive to reap the longer-term benefits of surgery. Keywords: Femoro Popliteal Bypass – Angioplasty - Trans Atlantic Inter Society Consensus.