Background: Critical limb ischemia is the most advanced stage of peripheral arterial occlusive disease. The prognosis is poor, with amputation rates up to 30 % and mortality up to 25% after 1 year. Objective: To compare using of balloon angioplasty versus bypass surgery in management of long superficial femoral artery (SFA) lesions. Patients and methods: A prospective comparative study conducted at the Vascular Surgery Department at Al-Azhar University Hospitals starting from November 2019 to November 2020. The study included (30) patients (15 patients were treated by angioplasty and 15 patients were treated by autogenous femoro popliteal bypass) suffering from long SFA lesions. Results: No statistical difference was found regarding age and sex distribution and associated comorbidities. Technical success rate after endovascular intervention (group A) reached 93.3% compared to 86.7% in femoropopliteal bypass (group B). Procedure duration was 1.1±0.85 compared to 2.8±1.7 in Group B. This was statistically lower in endovascular group (P=0.032). Mean hospital stay was 0.6±0.35 compared to 3.1±2.6 in Group B. This was statistically lower in endovascular group (P=0.013). We achieved a limb salvage rate of 14 (93.3%) in group A and 13 patients (86.7%) for group B and a major amputation rate of 6.7% (1 patients) in group A and 13.3% (2 patients) in group B over 1-year follow-up period. No difference was found between both interventions.      Patency rate at 12 months was higher in group B than in group A (66.7% vs. 46.7%). P=0.27. Postoperative improvement of ankle brachial pressure index (ABPI) was statistically non-different (P=0.07, 0.89). Superficial infection, Deep infection and Seroma were all confined to bypass group. Other complications were not statistically different in both groups. There was no significant difference in the mortality rate which was 6.7% and 13.3% in group A and B respectively. Conclusion: Both balloon angioplasty and bypass surgery were safe and effective method for treatment of long SFA lesions. Bypass group showed better patency rates at final follow up.