Old and frail patients undergoing vascular surgery seem at great risk of developing postoperative delirium (POD). The aim of this review was to identify risk factors for the development of POD in vascular surgery patients. Different aetiological factors have been identified, such as increased age, excessive blood transfusion, preoperative cognitive impairment and depression. Mounting evidence supports a role for inflammation and tobacco exposure in the development of POD. Vascular surgery patients differ from the general surgical population because they suffer from both loco-regional and systemic atherosclerosis. Although current scientific evidence cannot fully link both entities, evidence is growing that suggests a relationship between systemic and cerebrovascular atherosclerosis and the development of POD.