OBJECTIVE Areas of anastomotic stenosis in lower-extremity bypass grafts (BPGs) were treated by means of directional atherectomy (DA) in hopes of achieving better patency rates than have been reported with percutaneous transluminal angioplasty (PTA). METHODS During a 4-year period, 17 patients (11 men and six women) with 23 areas of anastomotic stenosis in 18 lower-extremity BPGs were selected for treatment with DA. Urokinase thrombolysis was initially performed in eight BPGs that were thrombosed at the time of presentation. Adjunctive preatherectomy PTA was performed in six lesions, and postatherectomy PTA was performed in three lesions. RESULTS The technical success rate for DA was 92% (23 of 25 sites). There was less than 50% restenosis at 74% of the areas of stenosis (14 of 19 sites), with a mean follow-up time for the sites of 13 months. The graft patency rate was 88% (14 of 16 grafts), with a mean follow-up time for the grafts of 14 months. Areas of stenosis treated with DA alone had the same patency rates as those treated with DA and PTA. CONCLUSIONS DA is an effective treatment method for anastomotic peripheral arterial BPG stenosis. The intermediate-term patency rates following DA are superior to those reported for PTA and similar to those reported for surgical revision.