Introduction Pedal (inframalleolar) bypass is a longstanding therapy for tibial arterial disease in patients with ischemic tissue loss. Endovascular tibial intervention is an appealing alternative with lower risks of perioperative mortality or complications. Our objective was to compare the effectiveness of these two treatment modalities with respect to patency and limb-related clinical outcomes. Methods We performed a retrospective chart review of patients presenting between 2006 and 2013 with ischemic foot wounds and infrapopliteal arterial disease who underwent a revascularization procedure (either open surgical bypass to an inframalleolar target or endovascular tibial intervention). Data was collected on baseline demographics and comorbidities, procedural details, and post-procedure outcomes. The primary outcome was successful healing of the index wound, with mortality, major amputation, and patency assessed as secondary outcomes. Results We identified 417 patients that met our eligibility criteria; 105 underwent surgical bypass and 312 underwent endovascular intervention, with mean follow-up of 25.0 and 20.2 months, respectively (P =.08). The endovascular patients were older at baseline (P = .009) with higher rates of hyperlipidemia (P = .02), prior cerebrovascular accidents (P = .04), and smoking history (P = .04). Within 30 days postoperatively, there was no difference in mortality (P = .31), but bypass patients had longer hospital length of stay (P < .0001), higher rate of discharge to nursing facility (P < .001), and higher rates of myocardial infarctions (P = .03) and wound complications (P < .001). At 6 months, the rate of wound healing was 22.4% in the bypass group compared to 29.0% in the endovascular group (P = .02). At 1 year, survival was higher after bypass (86.2% vs. 70.4%, P < .0001), but freedom from major amputation was similar (84.9% vs. 82.8%, P = .42). Primary patency (53.1% vs. 38.2%, P = .002) and primary assisted patency (76.6% vs. 51.7%, P < .0001) were higher in the bypass group, but there was no difference in secondary patency (77.3% vs. 73.8%, P = .13). Conclusions Endovascular tibial intervention is associated with poorer primary patency but similar secondary patency and wound healing rates compared to the gold standard of surgical bypass to a pedal target. In patients with tibial arterial disease, endovascular intervention should be considered as a lower-risk alternative to pedal bypass that provides similar clinical outcomes.