Objective: To investigate the safety and efficacy of Silverhawk atherectomy and adjunctive angioplasty in treatment of severe arterial atherosclerotic occlusive lesion below the knee. Methods: The clinical and follow-up data of 9 patients with this condition treated over the past 2 years were retrospectively analyzed. Of the patients, 3 cases were male and 6 were female, with a mean age of (64.0±9.1) years and mean disease course of (28.9±25.9) months; 5 cases had intermittent claudication, one case had rest pain, one case had toe ulcer, and 2 cases had toe gangrene; the occlusive lesion in 6 cases was located in the tibioperoneal trunk, in one case in the anterior tibial artery, and in 2 cases in the posterior tibial artery; one case underwent plaque excision alone and the other 8 cases underwent simultaneous endovascular procedure for the inflow arterial lesion. Results: All operations were successfully performed, and the recanalized artery was patent in all patients at discharge. The claudication distance increased to more than 500 m in the 5 claudication patients and the case with rest pain was relieved; the wound size of the one case with toe ulcer was reduced, and the gangrene in the 2 patients became dry and was not infected. Postoperative ankle brachial index (ABI) was increased in all patients compared with their preoperative value. All patients were followed-up for an average of (24.0±9.5) months. One patient died 23 months after operation due to myocardial infarction; claudication distance in one patient was decreased compared with the former best postoperative distance, but was still longer than the preoperative distance; the wound was healed in the ulcer patient; the rest pain that was present in one patient was relieved; of the 2 patients with toe gangrene, the dry state was kept in one case and in another case, the two gangrenous toes spontaneously detached and the wounds were healed. Conclusion: Silverhawk atherectomy and adjunctive angioplasty is a safe and effective method in treatment of severe arterial atherosclerotic occlusive disease below the knee, whereas, whether it will become a conventional treatment modality requires the verification by long-term results from randomized controlled trials.