Plaque Removal Versus Open Bypass Surgery For Critical Limb Ischemia

Inclusion Criteria: * Ischemic rest pain for more than 2 weeks or ulceration or gangrene of the foot or toes (Rutherford Becker Category 4, 5 or 6) * Willing and able, as evaluated by the PI, to provide Informed Consent * Willing to undergo up to 5 years of clinical follow up visits as scheduled * Angiographic pattern of infrainguinal disease that can be reasonably managed either by surgery or plaque excision in the first instance * Reconstitution of at least one patent target tibial segment below the knee which provides run-off to the foot * The patient must be \>18 years of age * Target lesion(s) is located at or below the level of the superficial femoral artery * Target lesion(s) is \>50% stenosed by quantitative vascular angiography * Ability to take at least one of the following types of medications: anti- platelet or anti-thrombotic therapy Exclusion Criteria: * Patient has cardiac or cardiovascular comorbidities that would make surgery inappropriate * Patient has terminal or Stage 4 cancer * Patient has extensive gangrene that requires both a Below-the-Knee amputation and a revascularization procedure * Previous stent in the target lesion * Active infection at planned incision site * The patient is a pregnant woman * The patient has significant suprainguinal or Common Femoral disease that can not be treated either prior to or during the index procedure * Target Lesion is a Chronic Total Occlusion (CTO) that is greater than 15cm in length and has severe, continuous calcification