Durability of open and endovascular interventions on patients with disabling claudication is a major concern, especially in those with complex anatomy needing infrainguinal reconstructions. The goal of our study was to compare our results of bypass versus endovascular interventions in a consecutive patient series and to determine effectiveness of treatment modality. All patients who presented with severely disabling claudication (Rutherford 3) with TASC II C or D disease, who underwent bypass, or infrainguinal endovascular (EV) interventions following failure of medical management between June 2001 and December 2008 were included. There were 56 patients in the EV group, and 56 patients in the open group. The comorbidities were similar, except there were more active smokers (68% vs. 46%, P = .035) and prior ipsilateral revascularizations (38% vs. 7%, P < .001) in the open group. Fifty-nine percent of bypasses were performed using polytetrafluoroethylene (PTFE). There were no 30-day postoperative mortalities. There were four superficial infections, one deep infection (necessitating graft removal), and one perigraft seroma in the open group. Technical success was 95% in the EV group. Length of stay was significantly less in the EV group (1.0 ± 1.3 vs. 5.1 ± 4.1 days, P < .001). The mean ankle-brachial index (ABI) increased from 0.55 to 0.94, similar in both groups. The mean follow-up was 29 ± 22 months. Primary, secondary patency, sustained clinical success rates (clinical improvement, freedom from target extremity revascularization (TER]), secondary clinical success (with TER) were similar (Table I), with a 36-month survival rate of 91 ± 4%. Only one patient had an amputation in the open group at 32 months. Fifteen patients (27%) in open and 20 patients (36%) in EV group required ipsilateral reinterventions (Table II; P = .419).Table IPatency rates and sustained and secondary clinical success ratesPPSPSusClSucSecClSuc12 mo36 mo12 mo36 mo12 mo36 mo12 mo36 moOpen79% ± 6%59% ± 8%82% ± 6%71% ± 8%77% ± 6%58% ± 8%85% ± 5%75% ± 7%EV69% ± 7%54% ± 8%86% ± 5%69% ± 9%67% ± 7%48% ± 8%92% ± 4%80% ± 8%P.162.942.120.387EV, Endovascular; PP, primary patency; SecCLSuc, secondary clinical success; SP, secondary patency; SusClSuc, sustained clinical success. Open table in a new tab Table IIReinterventions in open and EV-treated groupsReinterventionsOpenEVThrombolysis + PTA/S68Repeat bypass57EV recanalization21Inflow/runoff EV intervention28Contralateral revascularization57Contralateral amputation20EV, Endovascular; PTA/S, percutaneous transluminal angioplasty/stent. Open table in a new tab EV, Endovascular; PP, primary patency; SecCLSuc, secondary clinical success; SP, secondary patency; SusClSuc, sustained clinical success. EV, Endovascular; PTA/S, percutaneous transluminal angioplasty/stent. Clinical benefit following endovascular and open interventions in patients with severely disabling claudication and TASC II C or D femoropopliteal disease is similar at three years. The clinical improvement without additional procedures is achieved only in half, and TER is required in about a third of the patients. Aggressive medical management of claudication is warranted before any (open or endovascular) interventions are planned, and patients should be informed of the expected outcomes.