Background: Directional (HawkOne/TurboHawk) and rotational (Jetstream) atherectomy are increasingly used in the management of femoral-popliteal steno-occlusive disease. There is little real-world data comparing the long-term outcomes of the two different devices Methods: A retrospective multi-institutional cohort study was conducted evaluating both efficacy (technical success, 12-month primary patency, target-lesion revascularisation rates) and safety outcomes (complication rate, major limb amputation, mortality). Outcomes were compared by device in addition to a subgroup analysis of in-stent lesions (ISR). They were compared using Fisher exact tests, multivariable logistic regression and propensity-score matching. Results: Across 163 limbs, median age was 71 years, 36 (22%) were female, 40% had chronic limb-threatening ischaemia, 44% were diabetic, and the modal lesion was TASC II. HawkOne/TurboHawk (n=47) trended toward fewer periprocedural complications than Jetstream (n=116) (17% vs 35%; adjusted OR 0.39, 95% CI 0.16�0.95, p=0.04) with no device difference seen for patency, TLR, mortality or amputation. ISR lesions (n=35) had a significantly lower 12-month patency loss than native lesions (68.8% vs 34.7%; p=0.001), independent of device (adjusted OR 3.93, 95% CI 1.68�9.19, p=0.002). Conclusions: Atherectomy device did not independently affect any of the evaluated efficacy outcomes. The trend toward fewer complications with directional atherectomy warrants prospective evaluation. ISR lesions conferred a four-fold lower 12-month patency rate when compared to native lesions.