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Atherectomy has become a vital complementary technology in the treatment of complex arterial disease especially in lesions with heavy calcification such that their treatment with balloon angioplasty and stenting is limited. New technologies have made atherectomy no longer a mere instrument of plaque removal in practice, but instead extremely sophisticated systems that can achieve specific and vessel-conforming manipulation of the plaque. This review discusses the recent generation atherectomy equipment directional atherectomy equipment, rotational atherectomy equipment, orbital atherectomy equipment, and laser atherectomy equipment and the clinical associations they have with lesion morphology, imaging guidance, and adjunctive therapies. It also dwells on the next-generation innovation such as AI-guided navigation, new energy-powered solutions, micro-atherectomy of distal vessels, and drug-based platforms that can enhance vessel healing and minimize restenosis. The most important issues including device-vessel interaction, embolic risk, operator learning requirements, economic limitations and regulatory complexity are critically evaluated. New direction of future development is determined, and the focus is placed upon smarter sensors, real-time imaging integration, nanotechnology, and predictive modelling of personalised treatment planning. Case studies show the performance in real life and reveal discrepancies between the theoretical performance and the actual results. All in all, next-generation atherectomy has tremendous potential to enhance the safety of implementation of the procedure, its efficacy, and its long-term vascular outcomes, when technological innovation proceeds with resolving the existing limitations in a systematic and evidence-based ways.