Background: The systemic nature of atherosclerosis compromises medium-term survival following major vascular surgery. Neutrophil lymphocyte ratio (NLR) is a simple index of systemic inflammatory burden which correlates with survival following percutaneous coronary intervention. Methods: Patients undergoing elective major vascular surgery in 2 tertiary vascular units were identified from prospectively maintained databases. Factors associated with 2-year mortality were assessed by univariate and multivariate analyses. Results: Over a 4-year period, 1021 patients underwent elective major vascular surgery (carotid endarterectomy, abdominal aortic aneurysm repair, lower limb revascularization). Two-year mortality was 11.2%. In multivariate analysis, preoperative NLR > 5 was independently associated with 2-year mortality (multivariate odds ratio [OR] 2.21; 95% confidence interval [CI] 1.22-4.01). Conclusion: Preoperative NLR identifies patients at increased risk of death within 2 years of major vascular surgery. This simple index may facilitate targeted preventive measures for high-risk patients.