Compare the therapeutic effects of directional atherectomy combined with drug-coated balloon angioplasty with drug-coated balloon angioplasty alone in the treatment of femoropopliteal arteriosclerosis obliterans. From June 2016 to June 2018 in our hospital, patients with femoropopliteal arteriosclerosis obliterans received endovascular therapy, they present with life-limiting claudication or severe chronic limb ischemia. The patients were randomized to receive directional atherectomy combined with drug-coated balloon angioplasty (n=45) or drug-coated balloon alone(n=49). 94 patients were enrolled in our study with 72 males and the mean age was 67±10 years. The mean lesion length was 112±64 mm. There were no significant differences in the baseline characteristics of patients and lesions between the two randomized groups(P>0.05). Flow-limiting dissections occurred more frequently in the DCB group (n=12; 24.5%) than the DA-DCB group (n=2; 4.4%; P=0.006). The technical success rate in the DA-DCB group was superior to the DCB group (95.6% vs. 75.5%, P=0.006). The mean follow-up was 16.7±6.1 months in the DCB group and 15.3±5.8 months in the DA-DCB group. No amputations were performed. The overall mortality in the DCB group was 4.1% (2/49) while all patients survived in the DA-DCB group. The 12-months and 24-months primary patency in the DA-DCB group were greater than the DCB group (80.5% vs. 75.7%, 67.1% vs. 55.1%), however using all available patency data, no significant differences over time were observed (P=0.377). In this study, directional atherectomy combined with drug-coated balloon angioplasty can decrease the flow-limiting dissection rate in the treatment of femoropopliteal arteriosclerosis obliterans compared with drug-coated balloon angioplasty alone. There was no significant difference between the two groups in terms of primary patency rate which was needed to be further clarified. Copyright © 2019. Published by Elsevier Inc.