This retrospective study compared mid-term outcome of a simple pedal bypass (n = 58) and branched pedal bypass (n = 42) constructed with reverse saphenous grafts in patients with peripheral arterial disease stage 5 or 6 and TASC D lesions. Patients were followed-up at regular intervals during the first two-and-a-half postoperative years. Survival analysis showed better primary (67% vs. 46% at 20 months, p < 0.05), assisted (74% vs. 54%, p < 0.01), and secondary (84% vs. 70%, p < 0.05) patency in branched pedal bypass compared to that of simple pedal bypass. The limb-salvage rate, survival, and the need for reoperation due to wound bleeding or infection were comparable. We suggest that branched pedal bypass should be attempted in patients, where at least one imaging modality showed patency of both the dorsal and plantar artery and where the saphenous graft of sufficient quality, caliber, and length can be safely harvested.