Purpose: Critical limb ischemia is the worst form of PAD, with 20% mortality within 6 months of diagnosis and 20% of patients receiving an amputation within 1 year. The biggest challenge in endovascular revascularization is multilevel chronic total occlusions (CTO), which account for 40%-50% of lesions. Treatment failure occurs in approximately 20%-40% due to inability to cross the lesion when utilizing single access. Few limited prior studies have shown that dual access, after failure of either antegrade or retrograde approach, can increase the success rate in superficial femoral artery CTOs. The purpose of this study is to evaluate the efficacy and safety of initial dual antegrade and retrograde access approach compared to single antegrade or retrograde approach for crossing any level of CTO. Materials and Methods: A retrospective analysis was conducted of patients who had at least 1 lower-extremity CTO treated by a single operator at a community hospital between August 2013 and January 2018. Patient and procedural demographics were collected and analyzed. Rutherford classes III-VI were included. Chi-Square and Fisher’s exact test were performed along with propensity score-matched (PSM) analysis with a confidence interval of 95%. The primary endpoint was crossing and treatment success. Patient and procedural demographics were analyzed to determine variables of treatment success and failure. Results: 141 patients were included with 88 in the single access cohort and 53 in the dual access cohort. Crossing success in the dual access cohort was 92.5% and 73.6% in the single access cohort (P=.010). Average lesion length was 145.7 ± 92.1 mm and 146.4 ± 111.0 mm, respectively. Dual access showed to be a very strong indicator of crossing success (P<.001 all-subject, and P=.001 PSM) and going subintimal was an indicator of failure (P<.001 all-subject, and P=.001 PSM). There was a low rate of complications with no statistical difference between both cohorts. Conclusions: Our study demonstrated initial dual-access approach compared to single access has shown significant success in crossing and treating peripheral CTOs. We believe this could have a major impact on successfully reducing the amputation rates.