Ultrasound guidance is increasingly used at medical care centers. Ante-grade femoral access is a good approach because it increases device support; improves the accessibility of distal vessels not accessible by the contralateral approach. Our aim for this study was to evaluate the effect of ultrasound guidance (USG) on the selection of endovascular femoral access and its role to decrease complications and limit risks for patients and staff. (210) patients were retrospectively randomized 1:1 to either fluoroscopic (105) or US guidance (USG) (105). The indication was CLI, excluding patients with significant disease of the distal aorta, iliac artery, CFA, and SFA origins, and those who are accessed by other means (Upper limb, graft, popliteal, or pedal). By using the US the ante-grade approach became more common in selected patients (70% vs.50%). With US guidance, 1st attempt pass success was (95% vs. 58% rate) .it also reduced the access complications rate (2.8% versus 29%). Ultrasound guidance may have a significant effect in access selection, decreasing complications, and reducing radiation risks.