Excimer laser atherectomy (LA) employs precision laser energy control (shallow tissue penetration) and safer wavelengths (ultraviolet as opposed to the infrared spectra in older laser technology), which decreases perforation and thermal injury to the treated vessels. Though extensively used by cardiologists for severe obstructive coronary artery disease, peripheral interventionalists have not accepted LA as a routine adjunctive technique for stenotic or occluded vessels. We report herein the technical and clinical outcomes with LA for complex peripheral vascular disease in patients deemed high-risk for conventional surgical revascularization. Over a 6-month period, 19 lesions in 15 high-risk patients (mean age 72 ±10 years) were treated with LA (308-nm spectral wavelength) followed by balloon angioplasty for limb-threatening ischemia (n = 10) and severe disabling claudication (n = 5). The lesions were located at the superficial femoral artery (n = 8), popliteal artery (6), and/or tibial vessels (5). The mean occlusion length was 10.3 ±2.3 cm. Laser catheter choice ranged from 1.4 to 2.5 mm depending on the target vessel diameter. Clinical examination, duplex ultrasound, and ankle-brachial indices were performed in follow-up visits. Immediate technical success was achieved in 16 (84%) lesions. In the 3 technical failures, inability to cross the lesion with a wire (n = 2) or vessel perforation (n = 1) precluded successful LA. Overall, primary patency as assessed by duplex was 57% (superficial femoral artery 71%, popliteal 60%, tibial vessels 25%). Clinical improvement was seen in 10 lesions (77%) that were successfully treated initially. One patient required below-knee amputation. At an average of 2-year follow-up, 6 patients who were initially successfully treated were alive (46%), including 3 patients (50%) with stable symptoms without the need for major amputation. Laser atherectomy is a useful adjunctive revascularization technique for high-risk patients with limb-threatening ischemia. This technique is especially beneficial in the treatment of ostial lesions, which may be prone to distal embolization, as well as total occlusions that can be traversed by a guide wire but not a balloon. Vascular surgeons should add LA to their endovascular armamentarium for the treatment of complex peripheral vascular disease in the high surgical risk patients. Further study of clinical outcome measures and comparison to other interventional techniques are warranted.