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Background: /aim: The aim of this study was to retrospectively compare the results of systematic preoperative coronary angiography ultimately followed by stenting in patients with asymptomatic coronary artery disease (CAD) undergoing open peripheral revascularization for peripheral arterial disease (PAD)., Patients and Methods: From January 2003 to December 2022, 276 patients having undergone open peripheral recanalization for PAD were retrospectively reviewed and divided into two groups. Patients in group A (n = 132), all without a history of coronary artery disease, had undergone standard cardiac evaluation (EKG and cardiac ultrasound) and systematic preoperative coronary angiography ultimately followed by percutaneous coronary intervention (PCI) for significant coronary artery stenoses, whereas patients in group B (n = 144) had only undergone standard cardiac evaluation prior to open peripheral revascularization. Mean length of follow-up was 60 months (range 12-130 months). The primary endpoints were occurrence of any long-term postoperative myocardial infarction (MI) and any complication related to coronary angiography and stenting. Secondary endpoints were long-term postoperative mortality, complications related to open peripheral revascularization and long-term peripheral bypass patency., Results: Fifty-three patients (40.0%; 95% CI: 32.0%, 48.0%) in group A had a significant coronary artery stenosis, 48(36.3%; 95% CI: 32.0%, 48.0%) underwent percutaneous intervention (PCI) and five (3.8%; 95% CI: 0.5 %, 7.0%) received coronary artery bypass grafting (CABG) before open revascularization. While no postoperative MI was observed in group A, seven MI occurred in group B (4.9%; 95% CI: 1.4%, 8.4%), one of which was fatal (p = 0.04). During the follow-up period, two non-fatal MI (1.5 %; 95% CI: 1.2%, 1.8%) occurred in group A, while 20 MI (14.1%; 95% CI: 8.5%, 19.7%) occurred in group B, five of which were fatal (p = 0.0001). No complications related to coronary angiography and stenting were observed. While no postoperative mortality was observed in group A, two patients (1.4%; 95% CI: -0.5%, 3.3%) in group B died, one due to a fatal MI and one due to an acute lower limb ischemia and multiple organ failure (p = 0.17). During follow-up, seven deaths (5.3%; 95% CI: 1.5%, 9.1%) occurred in group A (five related to cancer, one to lung disease and one for unknown causes) and 16 (11.0%; 95% CI: 6.0%, 16.0%) in group B (five related to MI, eight to cancer, and two of unknown causes) (p = 0.07). Concerning complications related to open peripheral revascularization, two compartmental syndromes (1.5%; 95% CI: -0.5%, 2.5%) occurred in group A and two (1.4%; 95% CI: - 0.5%, 2.5%) in group B (p = 0.93) in group B (p = 0.93), without indication to perform fasciotomy, no prosthetic infection was observed in either group, and one bypass occlusion (0.7%; 95% CI: - 0.7%, 2.1%) occurred in group B with acute lower limb ischemia (p = 0.34). Peripheral bypasses were patent in 90 patients in group A (68.0%; 95% CI: 64.0%, 72.0%) and in 96 patients (67%; 95% CI: 59.4%, 74.6%) in group B (p = 0.78)., Conclusion: Systematic preoperative coronary angiography ultimately followed by PCI in patients selected for open lower limb revascularization is safe and reduces intraoperative and postoperative risk of MI., (Copyright © 2025. Published by Elsevier Inc.)