Peripheral Arterial Disease in the US: Amputation is Not the Answer

At the recent American College of Physicians Internal Medicine Meeting 2025, April 3-5, in New Orleans, Foluso A. Fakorede, MD, CEO and owner of Cardiovascular Solutions of Central Mississippi/Fusion Vascular, in Cleveland, MS, presented a compelling overview of peripheral arterial disease (PAD), highlighting the critical gaps in diagnosis, treatment disparities, and opportunities for improved outcomes.

An Underrecognized Epidemic

Foluso Fakorede, MD

Fakorede, an interventional cardiologist and endovascular specialist, opened with sobering statistics: approximately 8.5-12 million Americans aged 40 and older have PAD, a condition with cardiovascular risk equivalent to those with previous myocardial infarction.

"PAD is the most prevalent, costly, and deadly disease most Americans have never heard of," Fakorede emphasized, citing data showing Black Americans are twice as likely to suffer from PAD and up to 4 times more likely to undergo amputation compared to White Americans, according to the US Department of Health and Human Services.

Fakorede highlighted the "PAD Pulse" survey findings, which found that while nearly 75% of Black and Hispanic adults report having diabetes, high blood pressure, or knowing someone who does, only 30% believe they could be at risk for PAD. Even more concerning, 91% of respondents would dismiss leg pain as "just part of getting older," and over half would wait more than a week with ongoing leg pain before calling their doctor.

Closing the Gap in Screening, Diagnosis

Current American Heart Association (AHA) recommendations suggest using the ankle-brachial index (ABI) to screen for PAD in high-risk adults:

• Age 65 years and older
• Age 50-64 years with traditional risk factors
• Age younger than 50 years with diabetes and additional risk factors for atherosclerosis
• Those with established atherosclerotic disease

The ABI, however, has important limitations, Fakorede said, particularly in patients with diabetes or chronic kidney disease, where medial arterial calcification can lead to falsely elevated values. Alternative measures like the toe-brachial index (TBI) may be more reliable in these populations.

In 2024, the recommendations from the American Diabetes Association's (ADA) Standards of Care were modified to include PAD screening with ABI testing in asymptomatic people with diabetes aged 50 years and older, those with microvascular disease, foot complications, or any end-organ damage from diabetes. ADA also recommends considering screening for individuals who have had diabetes for 10 years or more.

Beyond Limbs at Risk: PAD's Clinical Impact

"PAD acts as a marker for systemic atherosclerosis, with 21% of adults with PADexperiencing MI, stroke, cardiovascular death, or hospitalization within one year, compared to 15% of patients with CAD," Fakorede stated, referencing data from the REACH Registry.

He stressed the polyvascular nature of the disease, pointing out that only 30% of patients having isolated PAD. The majority have concomitant coronary artery disease (46%), cerebrovascular disease (8%), or both (16%), according to Mahoney et al.

Fakorede outlined the “PAD Prescription,” a comprehensive approach to management that focuses on 3 key outcomes:

1. Preventing death, MI, and stroke: Antiplatelet/anticoagulant therapy, cholesterol-lowering medications, ACE inhibitors, and SGLT2 inhibitors

2. Reducing symptoms: Exercise, cilostazol, and revascularization when appropriate

3. Saving limbs: Endovascular or surgical interventions

Fakorede cited 4 landmark trials supporting medical management of PAD: the Heart Protection Study (2007), IMPROVE-IT (2016), FOURIER (2018), and COMPASS (2017), which all demonstrated that low-dose rivaroxaban plus aspirin reduces major cardiovascular events and adverse limb events compared to aspirin alone.

Amputation Inequities

The data Fakorede presented reveals a troubling pattern of inequity in lower limb amputation rates across the US. Black individuals are twice as likely to suffer limb loss compared to White counterparts, and in some regions, this disparity stretches to 4 times higher. Fakorede stressed that these disparities extend beyond race to include socioeconomic status (SES) and geography—patients with low SES or living in rural areas were significantly less likely to receive critical vascular care before amputation. Perhaps most alarming was the revelation that 69% of amputees received no revascularization attempts in the year prior to surgery, with 92% of these patients never even receiving basic angiography.

The statistics from congressional districts in Mississippi, where amputation rates reach 170.1 per 100,000 (compared to the national average of 45.5), illustrate how these disparities concentrate in specific communities. "For some reason, it is considered conservative treatment to chop someone's leg off and aggressive treatment to even do an angiogram," Fakorede quoted Dr. Craig Walker.

Recent research published in Circulation: Cardiovascular Quality and Outcomes further highlighted these disparities. Among 73,237 Medicare patients who underwent major lower extremity amputation, Black patients were less likely to have an outpatient vascular specialist visit (adjusted odds ratio 0.87) or revascularization (aOR0.90) than White patients. Similar disparities were observed for patients with low SES and those residing in rural areas.

A Call to Action: Policy and Practice

Fakorede provided detail on the Amputation Reduction and Compassion (ARC) Act (H.R. 307), which was introduced to the House of Representatives in 2020 and reintroduced in 2025. The legislation would authorize funds to establish a PAD education program through HHS, establish coverage of PAD screening tests without cost-sharing under Medicare and Medicaid for at-risk individuals, and require development of quality measures to reduce PAD-related amputations

Fakorede concluded with a summary of the "Get a Pulse on PAD" campaign, a collaborative effort by the Association of Black Cardiologists, Society for Cardiovascular Angiography & Interventions, Society of Interventional Radiology, and Society for Vascular Surgery, which aims to:

• Raise awareness about the "3 for PAD" - high blood pressure, diabetes, and tobacco use as top risk factors
• Encourage patients not to ignore symptoms, particularly leg pain while walking that resolves with rest
• Empower patients to initiate conversations with their healthcare providers

"Early detection through appropriate screening of at-risk populations is key to preventing the devastating consequences of PAD," Fakorede concluded, emphasizing the need for a multispecialty approach to this complex disease.