Background: Peripheral arterial disease (PAD) is a medical condition of growing magnitude that usually results from atherosclerosis and subintimal cholesterol deposition leading to stenosis or occlusion in the major arteries supplying the lower extremities. Worldwide prevalence of PAD is estimated to be around 10%. In general, bypass surgery is better adopted for long SFA occlusive lesions of more than 25cm length. Using an autologous vein graft is generally more preferable, especially whenever the patient's general condition permits, provided that the patient's life expectancy is more than 2 years. Endovascular treatment is an attractive alternative to open surgical procedures for PAD.  Aim of the work: This prospective cohort study aimed at detecting the role of endovascular management for surgical high risk patients with TASC II D femoro-popliteal occlusive diseases. The primary end point was limb salvage, and secondary end points included amputation free survival, binary restenosis.  Patients and methods: This is a prospective non randomized cohort study which included 54 surgical high risk patients with TASC II D femoro-popliteal occlusive diseases .It is a single arm clinical study with no comparison with open surgery result. The protocol was approved by the local ethics committee of Ain Shams University hospitals and all patients signed an informed consent form.  Results: 54 patients were included: 14 men (25.9%) and 40 women (74.1%).Technical success was reported in 48/54 cases (88.9%), and 6 cases failed (5 received bypass, 1 underwent major amputation). The primary patency within 2 years was 70.9%, assisted primary patency was 73.33 % and secondary patency was 68.18%. Conclusion: Endovascular management has an effective role in the treatment of TASC II D femero-popliteal occlusive diseases in surgical high risk patients and the limb salvage. Drug eluting balloons have lower incidence of restenosis and need for intervention in comparison to standard balloon. Stent insertion is associated with high incidence of re-intervention in comparison to balloon only angioplasty.