OBJECTIVES: Atherothrombosis is the leading cause of death worldwide with huge economic burden.  Peripheral arterial disease (PAD), a marker of disseminated vascular disease, puts patients at a high risk of atherothrombotic events.   The REACH Registry is an international prospective registry of 67,888 patients from 44 countries at risk of atherothrombosis due to coronary artery disease (CAD), cerebrovascular disease (CVD) and/or PAD, or the presence of  ≥ 3 atherothrombotic risk factors.  PAD at enrollment was identified on the basis of current intermittent claudication with either ankle brachial index (ABI) <0.9, or history of lower limb revascularization (angioplasty/stenting, peripheral bypass graft) or amputation.  METHODS: We examined 2-year rates of vascular-related hospitalizations and associated costs in 1303 REACH patients from Germany with established PAD at baseline.  Poisson regression was used to identify independent predictors of vascular hospitalizations.  The costs per DRG for vascular hospitalizations were derived from the German 2004 Case Fees Catalogue. RESULTS: At baseline, mean age was 68 years, 29% female, 46% diabetes, 76% had ABI <0.9, 56% had prior lower limb revascularization, 13% prior amputation, 63% had other involved vascular territories (479 CAD+PAD; 136 CVD+PAD; 205 CAD+CVD+PAD). There were 360 (28%) patients who had ≥1 vascular hospitalizations at 2 years.  Significant (p<.05) independent baseline predictors of an increased hospitalization rate included diabetes, female, ABI <0.9, prior peripheral revascularization, prior amputation, CAD, hypertension, decreasing age and prior smoking.  Mean vascular hospitalization costs per patient were: €2595 overall; €3052 female/€2423 male; €3351/€1973 with/without diabetes; €2773/€2394 with/without prior lower limb revascularization; €2787/€2578 with/without prior amputation.  Vascular interventions account for 61% of hospitalization costs, overall. CONCLUSIONS:  Rates and costs of vascular events/interventions are high in patients with PAD, and increase with identifiable risk factors.  Risk factor modification and prevention efforts are needed to lessen the burden of atherothrombotic disease for PAD patients, and society.