Conventional plain old percutaneous balloon angioplasty (POBA) of totally occluded coronary lesions have been reported to have a low incidence of initial success and high rates of reocclusion and restenosis. Directional coronary atherectomy (DCA) possesses the advantage of removing the occluding material be it atheromatous, thrombotic or fibrotic tissue. The achieved minimal luminal diameter (MLD), restenosis rate, reocclusion rate and late loss observed in 16 patients managed with DCA were compared to that in 28 POBA patients. Immediately after the procedure the MLD by DCA (2.83±0.45 mm) was significantly (p<0.05) larger than by POBA (2.22±0.35 mm). The late MLD was likewise significantly (p<0.05) larger after DCA (1.61±0.83 mm) even comparing 6 months vs 3 months after POBA (0.90±0.90 mm). Although there was no statistically significant difference in the late loss (DCA = 1.42±0.96 mm vs POBA = 1.07±0.84 mm), the reocclusion rate by DCA was significantly (p<0.05) less (6.8%) than by POBA (32%). Thus DCA seems to be more effective than POBA in the management of rurally occluding lesions, and the lower incidence of reocclusion seems to be related to the larger achieved MLD.