Peripheral artery disease (PAD), defined as an ankle brachial index (ABI) less than 0.9, is estimated to effect approximately 21 million people in the United States . The population age and prevalence of diabetes are both rising, which will ultimately lead to more patients with PAD . The most common arterial location affected by PAD is the superficial femoral artery (SFA) . An endovascular-first approach for many SFA lesions has been advocated in intersociety guidelines for many years . Unfortunately, data guiding the optimal efficient approach to revascularization of the SFA, particularly in the context of a chronic total occlusion (CTO), are limited and often driven by operator preference, experience, ability, and specialty background.