Purpose: To describe the feasibility of balloon angioplasty using a long balloon for chronic femoropopliteal occlusions by evaluating angiographic dissection patterns for optimization of outcomes in balloon angioplasty. Methods: A retrospective, single-center analysis examined 101 symptomatic patients (mean age 75.6±9.9 years; 65 men) with single de novo femoropopliteal occlusive lesions treated with balloon angioplasty between August 2012 and October 2016. The patients were classified into 2 groups for comparison of angiographic dissection patterns: 51 patients were treated with balloon angioplasty using long balloons (L-BA; defined as ≥220 mm in length) and 50 patients were treated with short balloon angioplasty (S-BA; defined as <150-mm-long balloons). Results: Severe vessel dissection patterns, defined as type C or higher, were fewer in the L-BA group (47.1% vs 70.0% in the S-BA group, p=0.019) and the total dissection length was shorter (92.7±72.6 vs 160.4±84.6 mm in the S-BA group, p<0.001). Although the results showed no significant differences between the two groups regarding the length of chronic total occlusions (L-BA: 228.6±73.2 vs S-BA: 226.0±53.8 mm, p=0.83), inflation pressure (L-BA; 8.2±2.6 vs S-BA: 8.1±2.9 atm, p=0.86), and the other lesion characteristics, inflation time was significantly longer in the L-BA group (161.2±68.7 seconds vs 51.1±54.0 seconds in the S-BA group, p<0.001). Multivariate analysis identified a balloon length ≥220 mm as an independent negative predictor of severe vessel dissection (odds ratio 0.29, 95% confidence interval 0.11 to 0.83, p=0.02). Conclusion: Using long balloons for balloon angioplasty may help prevent severe vessel dissection in chronic femoropopliteal occlusions.