Coronary embolization is a complication of coronary intervention procedures. The incidence, predictors, and clinical significance of this phenomenon during directional atherectomy were examined in 111 consecutive patients who underwent directional atherectomy to 120 lesions. Distal embolization occurred in 31 (28%) of the patients. It was noted mainly in the saphenous vein graft group of patients (12 [48%] of 25) versus the native coronary group (19 [22% of 86]; p = 0.01). Clinical predictors were age and de novo lesions. Morphologic predictors were larger artery size, larger postprocedure minimal luminal diameter, calcific lesions, and type C lesions. The only difference in clinical outcome was a longer hospitalization in the distal embolization group with 3.9 +/- 3.7 days versus the rest of the patients 2.4 +/- 2.4 days (p = 0.01). In the majority of patients there was no significant adverse clinical outcome.