The fate of the circulatory system in response to vascular injury is governed by a series of complex biochemical reactions involving cellular elements and plasma proteins. Alteration of this hemostatic balance can result in excessive bleeding or procoagulant complications. In the field of vascular surgery, modulation of this process can have severe implications with respect to the maintenance of vascular conduit patency by avoiding thromboembolic events and the prevention of excess bleeding in the operative setting. The nature of the hemostatic response in the setting of surgical-induced injury and stress is increasingly complex and not fully understood. When faced with the management of bleeding in the operative setting, the vascular surgeon must first understand the theories of hemostatic regulation before adapting these concepts to the surgical milieu. This review addresses the management of blood loss in the setting of vascular surgery. In so doing, insight will be shed on the interdependence and manipulation of hemostatic events as they relate to surgery. Topics related to preoperative evaluation, surgical technique, monitoring, and pharmacologic manipulation will be discussed.