BACKGROUND Anemia is a risk factor for adverse outcome in patients with symptomatic cardiovascular disease. This study assessed the association of preprocedural hemoglobin with adverse outcome in patients with advanced peripheral vascular disease (PVD) undergoing percutaneous transluminal angioplasty (PTA). METHODS Consecutive first-time procedures for patients with Rutherford category 4 or 5 PVD who underwent successful nonemergency PTA were analyzed in a retrospective cohort study. Cardiovascular risk factors, preprocedural hemoglobin, and angiographic data were recorded. Preprocedural (<or=24 hours) hemoglobin was divided into tertiles (first tertile: 10.5 +/- 0.7 g/dL; second tertile: 12.0 +/- 0.4 g/dL; third tertile: 13.9 +/- 0.9 g/dL). Study end points were a composite of adverse peripheral vascular events consisting of target lesion revascularization (repeat PTA or vascular bypass operation), limb amputation, or death. Cox regression analysis was used to identify independent predictors of adverse peripheral vascular outcome. RESULTS A total of 101 patients (mean age, 76 +/- 10 years) were studied, of which 54 (53%) were men, and 62 (65%) were anemic. We observed 42 events during a median of 14 months (interquartile range, 4-26 months follow-up). Cox regression analysis found preprocedural hemoglobin in the first tertile vs third tertile (odds ratio, 4.17; 95% confidence interval, 1.56-11.16, P = .004), diabetes, renal failure, Rutherford category 5, and tibial vessels runoff score were independent predictors of adverse peripheral vascular outcome. CONCLUSIONS Anemia is a common comorbid condition in patients with advanced PVD. Preprocedural hemoglobin could be used in clinical practice to risk stratify patients with advanced PVD who are being considered for PTA. Correction of anemia before PTA in patients with Rutherford category 4 and 5 PVD may improve long-term outcome. Further investigation is needed regarding the optimization of preprocedural hemoglobin.