Background: Thromboelastography (TEG) and coagulation tests can be used to detect hypercoagulability to assess thrombus formation. This study explored the association between TEG and coagulation in evaluating disease severity in elderly patients with lower extremity arteriosclerotic occlusive disease (LEASO), aimed to provide surgical treatment guideline.Methods: We retrospectively analyzed the clinical characteristics, laboratory biomarkers, TEG and coagulation parameters of 233 elderly LEASO patients treated between 2020 and 2023. Among them, 86 underwent surgical amputation, 51 received vascular intervention, and the remaining were treated conservatively. Differences in TEG and coagulation among the three groups were assessed using Spearman's correlation. Multivariate logistic regression and receiver operating characteristic curves analyzed the relationships among TEG, fibrinogen (FIB), and D‐dimer (D‐D) levels for surgical evaluation.Results: Inflammatory factors, platelet counts, and Fontaine stages III‐IV differed significantly between the surgery and conservative groups (p < 0.05). The surgery group had higher α‐angle, maximum amplitude (MA), coagulation comprehensive index (CI), FIB, and D‐D, whereas lower clotting time (K) compared to the conservative group (p < 0.05), correlated with a lower ankle brachial index (ABI), indicating more severe clinical presentation. Spearman's analysis identified positive associations between α‐angle, MA with FIB and D‐D levels in surgical patients. Area under curve analysis indicated that combining MA, α‐angle, FIB, and D‐D could enhance accuracy in evaluating surgical necessity in LEASO.Conclusion: In elderly LEASO patients, TEG and coagulation analysis revealed a positive association between thrombus intensity and disease severity. Increased MA, α‐angle, FIB, and D‐D levels serve as predictors for surgical treatment necessity in LEASO.