After endovascular therapy, duplex ultrasound surveillance to detect restenosis guides clinical decisions and defines treatment failure. However, the correlation between duplex ultrasound and symptom recurrence remains unclear. We reviewed our institutional experience (2007–2010) to identify patients undergoing endovascular therapy for claudication. The association between post-intervention systolic velocity ratio and patient-reported symptom recurrence was determined. We analyzed 183 follow-up visits following treatment in 88 limbs (femoropopliteal (56%) or iliac (44%) arteries). After femoropopliteal intervention, median systolic velocity ratio was higher in patients with symptom recurrence (2.99 symptomatic vs. 1.69 asymptomatic; p < 0.001). Elevated systolic velocity ratio or occlusion correlated with symptom recurrence (area under receiver operator characteristic curve = 0.82 [95% CI 0.74–0.83]), and systolic velocity ratio >2.5 was 71% sensitive and 72% specific for symptom recurrence. After femoropopliteal endovascular therapy for claudication, duplex ultrasound-detected restenosis is highly associated with clinical deterioration. This validates objective criteria for treatment failure in claudicants and suggests that symptom status can serve as a primary indicator of anatomic restenosis.