Significant local dissection at the site of angioplasty remains the most common cause of complications at balloon dilatation. In the past, the only solution was to transfer the patient for emergency coronary artery bypass grafting. Recent improvements in equipment and increasing experience mean that alternative instrumental methods are now available to manage dissection; in particular, by directional atherectomy and stent implantation, thus possibly avoiding surgery. In this article, the use of atherectomy as management for acute local dissection will be discussed, with special reference to the potential difficulties which may be encountered. Data showing that excellent immediate results and good long-term success can be achieved with atherectomy for acute dissection using careful selection criteria will be presented, indicating that atherectomy is a valid alternative instrumental treatment for the management of such dissection.