Introduction: Contrast-induced nephropathy (CIN) is a well-known complication of conventional fluoroscopy guided angioplasty procedures and is associated with increased patient morbidity and mortality. In this feasibility study, we tried to perform the angioplasty procedures under duplex guidance alone without the need to give the potentially nephrotoxic contrast agents especially in renal impairment patients while reducing the radiation exposure. Objectives: To examine the feasibility of performing peripheral femoro-popliteal endovascular procedures under duplex guidance alone with assessment of initial technical success, procedural complications, and clinical improvement after 3 & 6 months. Patients and method: This study included patients with peripheral arterial diseases (PAD); (Rutherford category: 3-6) and laboratory evidence of renal insufficiency presented to the outpatient clinic between (January 2014 to October 2015), who proved by arterial duplex examination to have >50% stenosis or complete total occlusion (CTO) of the femoro-popliteal arterial segment affecting the middle or lower 1/3 of the superficial femoral artery (SFA) and/or popliteal artery (PA). Results: 21 patients (15 males & 6 females) with serum creatinine levels of ≥ 1.5 mg/dL were selected. Ages ranged from 50 to 72 years (mean: 61 ± 3.5 years). Disabling claudication was the indication in 11 cases (52%) and critical ischemia in 10 (48%). Isolated popliteal artery lesions were found in 3 cases (14 %) and lesions involving the SFA alone were found in 6 cases (29 %), while significant lesions in both the SFA and PA were found in 12 cases (57%).The mean length of the lesions in this study was 14 ± 4 cm. Immediate technical success was confirmed by completion duplex scan and was documented in all cases. Procedure duration ranged from 45 to 130 minutes (median: 87 minutes). Placement of nitinol self-expandable stents was needed in 13 (62%) cases. The reason for stent placement included: arterial dissection in 9 cases (43%) and plaque recoil in 4 cases (19%). 10 cases needed a single stent while in 3 cases 2 stents were necessary. 11 stents were deployed in the SFA and the remaining 5 stents were in the above knee popliteal segment. For stenotic lesions, the mean peak systolic velocity (PSV) prior to treatment was 340 mm/s and was 120 mm/s after angioplasty with an average reduction of 64%. Mean PSV 2 weeks following duplex guided angioplasty (DGA) was 129 mm/s, showing a reduction of 62%. For all lesions, mean preoperative ABI was 0.64 and improved to 0.83 postoperatively. No distal emboli were detected on completion duplex scans. Three procedural complications were observed in the form of 2 groin hematomas and 1 vessel perforation which was detected by color flow imaging. Conclusion: Patients at risk of developing contrast induced nephropathy, or those with proven allergies to iodinated contrast media, duplex ultrasound guided PTA presents a fairly safe and performable alternative to conventional PTA. Key Words: Duplex guided angioplasty, Femoro-popliteal occlusive disease.