Abstract Body: Background:
Peripheral artery disease (PAD) and chronic limb-threatening ischemia (CLTI) are major causes of limb loss and healthcare utilization. Timely revascularization is essential for limb salvage, yet access to advanced vascular care may vary by hospital location. Contemporary nationwide data on rural–urban disparities in PAD/CLTI management are limited.

Objectives:
To evaluate rural–urban differences in revascularization, major lower-extremity amputation, and inpatient outcomes among patients hospitalized with PAD and CLTI.

Methods:
We conducted a retrospective cross-sectional analysis of the 2022 National Inpatient Sample. Adult hospitalizations with PAD ± CLTI were identified using ICD-10-CM codes. Hospitals were categorized as urban teaching, urban non-teaching, or rural. Primary outcomes were receipt of any lower-extremity revascularization and major amputation. Secondary outcomes included in-hospital mortality, length of stay (LOS), and total hospitalization cost. Survey-weighted multivariable logistic regression adjusted for demographics, comorbidities, payer status, disease severity, and hospital characteristics.

Results:
Among approximately 100,000 weighted PAD/CLTI hospitalizations, 50% (~50,000) occurred at urban teaching hospitals, 30% (~30,000) at urban non-teaching hospitals, and 20% (~20,000) at rural hospitals. Patients treated at rural hospitals were older, more often White and Medicare-insured, and had higher burdens of diabetes, kidney disease, cardiovascular disease, smoking history, and CLTI (all p<0.001). Revascularization was less frequently performed in rural hospitals (48.2% [9,637 of 20,000]) compared with urban teaching centers (55.2% [27,616 of 50,000]), whereas major amputation occurred more often (29.3% [5,864 of 20,000] vs 17.4% [8,679 of 50,000]; p<0.001). In adjusted analyses, treatment at rural hospitals was associated with lower odds of revascularization (aOR 0.70, 95% CI 0.67–0.72) and higher odds of major amputation (aOR 1.60, 95% CI 1.53–1.66) in addition to higher in-hospital mortality (7.4% [1,474 of 20,000] vs 5.5% [2,736 of 50,000]).


Conclusions:
Significant rural–urban disparities persist in PAD and CLTI care. In rural hospitals, lower use of revascularization coincides with substantially higher rates of major amputation and in-hospital death, emphasizing the need to strengthen referral pathways, expand access to vascular expertise, and improve coordination of limb-salvage care for rural patients.