OBJECTIVES: To perform an incremental cost analysis of the Cardiovascular Systems Inc. Orbital Atherectomy System in conjunction with angioplasty (OAS+BA) compared to angioplasty alone for the treatment of critical limb ischemia (CLI) from the hospital perspective.  METHODS: A deterministic decision tree simulation model was constructed using MS Excel. The perspective of the model was a United States (US) hospital. Clinical and healthcare utilization data were obtained from the CALCIUM 360 randomized clinical trial. Cost data were obtained from the published literature. All costs were adjusted to 2015 dollars using the Medical Care Component of the Consumer Price Index. The simulation model estimated the incremental cost due to adverse events and BA and/or OAS-related unit costs. The following utilization measures were included in the simulation model: OAS device, balloon(s), and bailout stent(s) (bare metal or drug eluting). The model computed the incremental cost to the hospital of performing OAS+BA versus angioplasty alone at 1 year.  One-way sensitivity analysis was performed.  RESULTS: Based on a hospital performing 100 procedures annually, the incremental costs to the hospital at 1 year were $290,230 lower with OAS+BA compared to angioplasty alone. These cost savings primarily reflected a reduction in target lesion and/or vessel revascularization and end of life care. Sensitivity analyses revealed these findings to be robust to the specified parameter value ranges. CONCLUSIONS: This analysis suggests that OAS+BA is associated with cost savings to the hospital of $290,230 at 1 year.