America’s Amputation Crisis (Part 4 of 4): The Path Forward to Save Limbs and Lives

This is the final article in a four-part series examining America’s preventable amputation crisis.

Read Part 1 here: The perfect storm threatening millions of limbs

….and Part 2 here: The evident double standard costing patients their limbs

…and [Part 3: Following the money behind the amputation epidemic.

“They approved the amputation immediately, but denied the procedure that could have saved his leg.”

The frustration in the doctor’s voice was palpable as he called me last month. He’s an interventional cardiologist in the Midwest who had been fighting for weeks to get approval for an advanced limb-salvage procedure for his patient with severe below-the-knee arterial blockages. The insurance company required a peer-to-peer review—but instead of connecting him with another vascular specialist, they assigned a gynecologist with zero experience in limb salvage.

Despite the doctor carefully explaining the tools he would use and the evidence supporting their effectiveness, the gynecologist denied the procedure, citing “insufficient evidence” for the device’s use below the knee.

While the doctor appealed the decision, his patient’s pain became unbearable. The wound on his foot grew increasingly inflamed. Unable to wait any longer, the patient went to a local emergency room where a different physician convinced him that an above-knee amputation was “the best approach to ensure no revolving door of amputations and quicker healing.”

The irony was stark: above-knee amputations carry the highest reimbursement rates, and the same insurance company that had denied a targeted procedure to save the patient’s leg approved the amputation without question—no peer-to-peer review, no evidence requirements, no waiting period. Just immediate approval for a life-altering amputation that was never medically necessary.

This story represents the most disturbing aspect of America’s amputation crisis: a healthcare system that has created perverse incentives favoring amputation over limb preservation. Throughout this series, I’ve documented how this crisis unfolds—from the evolving “bottoms up” pattern of PAD to the evidence double standards and financial incentives that drive unnecessary amputations.

Now it’s time to focus on solutions:

Early detection: Breaking the cycle before it starts

The most effective solution to the amputation crisis is detecting peripheral artery disease (PAD) before it progresses to limb-threatening stages. This is our first line of defense against unnecessary amputations.

Congress is now considering legislation that would make early testing the national standard of care. The Amputation Reduction and Compassion (ARC) Act, which stalled following the passing of its original champion, the late Representative Donald Payne Jr., was reintroduced in January 2025 by Representatives LaMonica McIver, Jonathan Jackson, and Robin Kelly. The bipartisan bill would require Medicare, Medicaid, and federal exchange plans to cover PAD screening for at-risk individuals—finally placing early detection on the same policy footing as other chronic diseases.

Hopes are high that this renewed effort can maintain momentum, though the current stance of the U.S. Preventive Services Task Force (USPSTF) could pose a hurdle. First issued in 2018 and still unchanged, the Task Force concluded there is insufficient evidence to determine whether the benefits of screening asymptomatic adults outweigh the risks.

Now, I do understand that the Task Force isn’t questioning the safety of the ABI test itself, but whether population-wide screening leads to better outcomes or puts patients at unnecessary risk—citing potential harms such as false positives or follow-up interventional or surgical procedures. But that reasoning doesn’t align with how other chronic diseases are handled. Colon and breast cancer screenings are approved for asymptomatic but high-risk individuals, despite higher diagnostic and treatment risks—colonoscopies can perforate the bowel; mammograms expose patients to radiation and often lead to biopsies or even overtreatment. Yet we accept those risks because we understand those diseases can silently advance without early detection.

The same logic should apply to PAD. Left undiagnosed, it can progress quietly—sometimes to limb loss, more often to heart attack or stroke. The difference is that PAD’s frontline treatment for asymptomatic patients, according to the 2024 PAD Management Guidelines, is conservative and risk-free: supervised exercise therapy, smoking cessation, dietary modification, and medication. There’s no chemotherapy, no radiation, no surgery—just prevention.

So if higher-risk, invasive cancer screenings are embraced as essential, how can a painless test with a blood-pressure cuff be considered “too risky”? The rationale simply doesn’t hold up.

At least we are seeing full speed ahead at the state level despite the Task Force’s position. In 2025, Illinois became the first in the nation to mandate insurance coverage for PAD screening. The law—championed by Dr. Foluso Fakorede, chair of the Association of Black Cardiologists PAD Initiative, working alongside the American College of Cardiology Illinois Chapter—requires insurers to cover testing for at-risk residents. It’s a model for other states seeking to reduce unnecessary amputations through early diagnosis.

Georgia isn’t far behind. Representative Kim Schofield is drafting legislation that could make her state the first in the South’s so-called “amputation belt” to adopt similar screening requirements—proof that progress can move forward even as national policy lags behind.

And as states step up, the broader ecosystem is responding. Industry partners are helping make these policy goals practical on the ground. Companies such as Biomedix are equipping frontline clinicians—primary-care physicians and podiatrists alike—with portable PAD testing systems that make in-office screening easier and more accessible.

At the same time, advocacy organizations like the Global PAD Association are reinforcing the importance of this shift. We strongly endorse these state-level and clinical initiatives and continue to advocate for mandatory ABI screening for patients over 40 with high-risk factors such as diabetes, kidney disease, high cholesterol, high blood pressure, aortic aneurysm, atrial fibrillation, autoimmune conditions like lupus, blood-clotting disorders, a history of smoking, and cardiovascular disease. This single, inexpensive test could prevent thousands of amputations each year by identifying disease early—when lifestyle changes, medications, and walking therapy can still make a difference.

But technology and policy alone can’t solve the problem. To truly break the cycle, education must reach the clinicians on the front line of patient care.

Primary care and podiatry education: The critical first line

Early detection can’t succeed without the people responsible for carrying it out. The first tangible opportunity to stop PAD from progressing doesn’t happen in Washington—it happens in the exam room. Primary care physicians and podiatrists are the gatekeepers, often the first to see the earliest signs of the disease: leg pain, cramping, neuropathy, numbness, tingling, or wounds that refuse to heal.

If passed, the Amputation Reduction and Compassion (ARC) Act would not only remove financial barriers to testing but also motivate more frontline clinicians to screen for PAD as a standard part of care. When coverage becomes the norm, awareness follows. But policy can only go so far without proper education.

In a Global PAD Association poll of more than 400 patients, more than 70 percent reported that when they first presented with textbook PAD symptoms, they were told their problems were due to diabetes, diabetic neuropathy, arthritis, fibromyalgia, gout, or simply “old age.” Each misdiagnosis cost precious time for intervention—months or even years during which disease silently advanced.

This isn’t neglect—it’s a training gap. Most primary care and podiatry programs dedicate limited time to vascular education, even though PAD affects more Americans than most cancers combine, according to a 2014 study published by Nehler et al, in the Journal of Vascular Surgery. As a result, the clinicians most likely to encounter PAD early are often the least equipped to recognize it.

Enhanced training would help frontline providers identify high-risk patients—those with diabetes, chronic kidney disease, high cholesterol, hypertension, hypercoagulability, or a history of smoking. Catching PAD at this stage allows for interventions when lifestyle changes, medications, and walking programs can still slow or even reverse progression.

Medical schools and residency programs should integrate comprehensive vascular disease modules, while continuing education requirements must emphasize PAD detection. Practice guidelines should also mandate routine ABI screening protocols for at-risk patients—a step supported by recent coverage initiatives outlined in the proposed ARC Act and by leaders such as Dr. Foluso Fakorede of the Association of Black Cardiologists, who continues to champion primary-care-level PAD screening in state legislation.

Early screening doesn’t just save limbs—it opens the door to effective, conservative treatment options like walking therapy.

Walking as medicine: A powerful but underutilized early treatment

Once PAD is identified, one of the most powerful treatments—walking—becomes medicine itself. According to the Society for Vascular Surgery’s Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia, walking helps patients grow new collateral vessels that reroute blood flow around diseased arteries, improving circulation and mobility.

Walking as medicine works. Yet despite its proven benefits, it remains one of the most under-prescribed and unsupported therapies in modern vascular care.

Take Sid, for example. He called the Global PAD Association’s Leg Saver Hotline after his doctors recommended an amputation. Not one of them had offered him a structured walking program. We connected him to our “My Steps” initiative, which gave him a second chance—not only at keeping his leg but at reclaiming his life.

Supervised Exercise Therapy (SET) remains one of the most effective yet underutilized tools for PAD management. Research in the Journal of Vascular Surgery found that structured walking programs can more than double walking distance in PAD patients—results comparable to surgical interventions in many cases. Medicare’s SET program was created to make this therapy accessible, covering up to 36 sessions over 12 weeks in hospital outpatient settings. In theory, it should be one of the most powerful, low-cost solutions for helping patients avoid amputation.

Yet the reality is stark. A 2023 JAMA analysis led by Dr. Kathleen Hammond found that only about five percent of eligible patients complete the program. Why such poor results? Recent studies have identified several critical barriers that expose deep structural gaps in how we deliver exercise therapy:

• Lack of physician referral: More than 85 percent of PAD patients say their doctor never prescribed or even mentioned SET, according to a review in Circulation: Cardiovascular Quality and Outcomes.
• Limited program availability: Over half of vascular specialists report no SET program at their facility.
• Knowledge gap: More than one in four specialists don’t realize SET is covered by Medicare.
• Financial burden: Only 41 percent of patients say they’re willing or able to pay the $11-per-session copay, the JAMA study found.
• Transportation challenges: Many patients decline SET because of travel distance or lack of transportation options, according to the same review.
• Scheduling inflexibility: Rigid hospital schedules make it difficult for working patients or caregivers to attend multiple sessions per week.

At the Global PAD Association, we recognized these obstacles and developed a fundamentally different approach. Our “My Steps” program addresses everything that makes traditional SET impractical. It’s remote, eliminating transportation barriers. It’s flexible, accommodating patients’ work schedules and personal obligations. It’s free, removing the financial hurdle that often keeps patients from completing care. And it’s trackable, allowing physicians and insurers to monitor progress and outcomes in real time.

The results speak for themselves. While traditional SET programs struggle to retain just five percent of participants, “My Steps” maintains a 75 percent retention rate—even beyond three months.

Recent studies validate this model. Research published in Vascular Medicine shows that digital walking interventions with goal-setting and progress tracking significantly improve both walking distance and adherence. Likewise, a 2023 Journal of Vascular Surgery study found that hybrid programs—combining a few weeks of supervised therapy followed by home-based walking with weekly coaching—achieved 87 percent completion rates and marked improvements in both mobility and pain reduction.

Sid’s story is proof of what’s possible. One year after being told his amputation was inevitable—when he could barely walk a few feet before needing to rest—he was walking miles through Walt Disney World with his grandkids, keeping up with every step.

Walking after procedures: The missing link

Perhaps most critically, structured walking programs should extend beyond initial diagnosis into the post-procedure period. That gap in current treatment protocols is vast—and deadly.

Here’s a stark truth few patients are told: no artery-opening intervention is permanently durable. Whether via angioplasty, stenting, or bypass, the purpose of these procedures isn’t to “fix” the arteries forever—it’s to restore enough blood flow to heal wounds and relieve pain so patients can start walking again.

Once patients walk, they stimulate the growth of collateral vessels—natural bypass channels that reroute blood around blockages. So even if those arteries eventually narrow or re-block, the goal is for patients to have developed enough alternate pathways through their walking regimen that the main arteries no longer need to be manually reopened to keep their legs intact.

Evidence supports this approach. Studies published in the New England Journal of Medicine and JAMA confirm that revascularization alone does not guarantee lasting improvement and may even accelerate complications, including amputation, when not paired with exercise-based follow-up. Patients who combine revascularization with structured walking demonstrate far greater long-term functional gains and lower amputation rates than those who undergo procedures without rehabilitation.

Yet in practice, SET-type walking programs are rarely prescribed post-procedure. Insurers often treat them as optional add-ons rather than essential parts of recovery. That must change. Structured walking and/or post-procedure physical therapy programs for CLI patients should be required and covered—not as a bureaucratic hurdle, but as a vital step to make limb-salvage procedures durable and prevent the “revolving door” of repeat interventions.

Reforming insurance: The gatekeepers of care

The most critical reforms must start with insurance coverage policies. The current system ignores substantial evidence showing better survival rates with limb salvage procedures compared to amputation. When an FDA-cleared device demonstrates safety and efficacy, insurance should cover it by default until proven otherwise—not the reverse.

This approach would mirror what we already do for cancer patients. Imagine telling someone with cancer, “We won’t try this treatment because you’re going to die anyway”—yet that’s essentially what happens to patients with critical limb-threatening ischemia (CLTI), what some doctors appropriately call “cancer of the legs.”

Troublingly, recent developments suggest we’re moving in the wrong direction. Industry reports indicate that despite public commitments to improve prior authorization systems, some health insurers are exploring AI-driven authorization programs that could further complicate access to specialized care for PAD patients.

Insurance reform should include:

1. Mandatory vascular evaluation before amputation approval: Research by Dr. Eric Secemsky of Beth Israel Deaconess Medical Center found that of the 60% of Medicare patients whom a doctor never tried to open up their arteries, approximately 90%  never even received a proper vascular evaluation at all. Insurance companies should require documented vascular assessment before approving any amputation.
2. Peer-to-peer review for amputations: Unless the patient’s life is in immediate danger, amputations should require the same level of scrutiny as limb salvage procedures, including peer-to-peer reviews with vascular specialists.
3. Adherence to society guidelines: Insurance companies should require documentation that physicians have followed Society for Vascular Surgery guidelines to attempt restoration of inline blood flow prior to approving amputation.
4. Streamlined approval for limb salvage: The current system where amputations receive immediate approval while limb salvage procedures face weeks of delays must be reversed. Time is tissue—delays directly contribute to preventable amputations.

I’ve witnessed this tragedy repeatedly through our Leg Saver Hotline. Take Deb from Georgia, whose story I shared in Part 3. Her insurer readily approved a $40,000 amputation despite no wounds on her feet, yet delayed a less expensive limb-saving procedure that ultimately preserved both her limb and life after weeks of unnecessary suffering.

PAD and CLI innovation without barriers

Perhaps the most troubling aspect of current insurance policies is how they stifle innovation. When companies invest in developing new technologies for limb salvage, they face extraordinary hurdles to reimbursement—while the 150-year-old amputation procedure receives automatic approval.

We need a new approach to evaluating limb salvage technologies:

1. Expedited Coverage for “Last Chance” Options: For patients facing imminent amputation, insurance should cover innovative approaches like deep vein arterialization (DVA) that show promising results in early studies.[7]
2. Coverage with Evidence Development: Instead of denying coverage until perfect evidence exists, implement coverage while collecting real-world data on outcomes.
3. Appropriate Comparators: Evaluate new limb salvage technologies against amputation outcomes, not just against other limb salvage techniques.[8]
4. Patient-Centered Metrics: Incorporate quality of life, mobility preservation, and patient preferences into coverage determinations—not just short-term cost calculations.

For patients like Thomas from Louisiana, whom I’ve worked with through our organization, these policies are literally life-changing. Despite his first physician recommending immediate amputation, Thomas found a specialist who has kept him ambulatory for three years through periodic minimally invasive procedures. He continues working and exercising regularly—yet each time he needs a procedure, his insurance company forces him to endure weeks of waiting and suffering.

Even when patients overcome insurance denials, many still face another kind of barrier—one hidden inside the very institutions meant to heal them. The structure of hospitals, the realities of physician workload, and the risks of radiation exposure all play quiet but powerful roles in determining who gets a limb-saving procedure and who ends up with an amputation.

Addressing hospital and physician barriers to limb salvage

Insurance reform is only part of the solution. Even when coverage is approved, another set of obstacles often stands in the way: the logistical and occupational barriers within hospitals themselves.

Complex limb-salvage procedures can take hours—sometimes four, six, or more—to navigate the smallest arteries in the legs and feet. During that time, interventional physicians are exposed to continuous radiation under fluoroscopy, often wearing heavy lead aprons that cause orthopedic strain. For many, the physical toll and long-term exposure risk become powerful deterrents.

Meanwhile, hospitals facing packed operating schedules or limited cath lab capacity may prefer shorter, higher-volume procedures over the marathon revascularizations required for advanced limb salvage. Amputation, by contrast, is a faster operation, reimbursed at higher rates, and carries little risk to the provider. The result is a quiet but powerful bias toward speed and safety for the physician over durability and recovery for the patient.

Hospitals must do more to protect and empower the physicians willing to take on these life-saving interventions. That starts with enforcing stricter radiation safety standards, investing in modern shielding systems, rotating lab teams to minimize exposure, and redesigning workflows to accommodate longer cases without penalizing the doctors performing them.

At the same time, medicine must evolve to clearly define who performs what kind of care. Not every physician who treats peripheral artery disease is trained—or willing—to manage the most advanced, high-risk cases of critical limb-threatening ischemia. There should be a clear distinction between general PAD practitioners and CLI specialists, sometimes called CLI Operators. These are physicians trained to perform complex, small-vessel interventions below the knee and into the foot, using advanced tools and techniques that can mean the difference between amputation and mobility.

Hospitals should establish multidisciplinary limb-preservation programs where these specialists collaborate across cardiology, vascular surgery, radiology, wound care, and podiatry. When such programs don’t exist, systems must allow patients to be transferred to hospitals that do.

No hospital that refuses to allocate the time, technology, or resources for limb salvage should default to amputation instead. Every patient deserves referral to a center of excellence—a facility equipped and staffed to assess whether their limb can be saved. And no amputation—unless truly emergent due to sepsis or irreversible infection—should proceed without review by a team that includes at least one CLI specialist.

Until hospitals, insurers, and health systems align incentives with patient outcomes, too many decisions will continue to favor convenience and cost over care.

Yet even when hospitals and physicians get it right, not every community has access to that kind of care. Across America, entire regions—and entire populations—are still being left behind.

Breaking Down Geographic and Racial Disparities

The amputation crisis does not affect all Americans equally. As I reported earlier in this series, Black Americans are up to four times more likely than white Americans to lose a limb from peripheral artery disease, even when the severity of their disease is the same. Across the southern United States—often called the “amputation belt”—rates can be as much as 500 percent higher than in other regions, according to national data published in the Journal of Vascular Surgery.

These disparities are not inevitable—they are systemic. They reflect differences in access, awareness, and advocacy, not biology. When Dr. Foluso Fakorede opened a dedicated limb-salvage center in the Mississippi Delta, one of the poorest and most medically underserved regions in the country, his team reduced major amputations by more than 87 percent within just three years. His findings, published in Vascular Disease Management in 2018, demonstrated what happens when evidence-based medicine, early detection, and community outreach intersect.

The lesson is simple but profound: when patients gain access to physicians trained in advanced limb-salvage techniques—and when screening and referral systems are built to reach them—amputation rates plummet.

To address these disparities on a national scale, policymakers and healthcare leaders must take targeted, measurable steps:

• Centers of excellence in underserved areas. Build comprehensive limb-preservation programs where they are needed most—especially across the southern U.S. and in rural and urban communities with high diabetes and PAD prevalence.
• Telemedicine networks. Create systems that allow smaller hospitals to consult remotely with advanced limb-salvage specialists before any amputation decision.
• Equity audits. Require insurers to track and publicly report amputation and revascularization approval rates by race, geography, and socioeconomic status to expose systemic bias.
• Mobile screening initiatives. Deploy Ankle-Brachial Index (ABI) testing and vascular assessments directly to high-risk communities, covered by insurance and supported through hospital incentives.

But solving disparities isn’t only about infrastructure—it’s also about education and representation. Patients in marginalized communities deserve providers who understand the unique barriers they face and who are equipped with the skills and resources to intervene early.

That means modernizing medical education to prepare future clinicians for the realities of today’s disease pattern, which increasingly affects the smallest vessels in the foot and leg. It also means cultivating a workforce that reflects the diversity of the patients most at risk—because trust and understanding are as vital to prevention as any diagnostic test.

Advancing education for modern pad

True equity in limb preservation requires more than access—it demands that the medical community itself evolve.

Many of today’s vascular specialists were trained when peripheral artery disease was largely understood as a “top-down” problem—blockages in the larger arteries above the knee. But over the past two decades, the disease has shifted, especially in rural communities of color where diabetes and chronic kidney disease are rampant. It’s increasingly a “bottom-up” condition, beginning in the smallest arteries of the feet and progressing upward. Treating it requires entirely different techniques, tools, and mindsets.

Medical education must catch up. Fellowship and residency programs should emphasize small-vessel interventions and advanced imaging for below-the-knee and pedal arteries. Training should include high-fidelity simulation labs where physicians can practice complex procedures before performing them on patients—mirroring the skill development required in cardiology or neurosurgery.

The shift from “top-down” to “bottom-up” also demands clearer professional distinctions. Not every clinician who treats PAD is equipped—or willing—to perform the intricate, high-risk interventions needed to save limbs threatened by critical limb-threatening ischemia (CLI). These procedures can take hours, often under continuous fluoroscopy that exposes operators to significant radiation. To ensure both patient and physician safety, medical institutions and specialty boards should create two distinct training pathways: one for PAD generalists who manage earlier-stage disease, and another for CLI specialists, sometimes called “CLI operators,” who focus on advanced limb-salvage care.

Such specialization would allow hospitals to build comprehensive limb-preservation teams that combine general PAD management with the intensive expertise required for complex CLI. It would also enable hospitals that lack this expertise to develop referral networks to centers of excellence, ensuring that every patient is evaluated by the right physician before amputation is even considered.

Beyond procedural training, PAD education must also expand into multidisciplinary collaboration. Cardiologists, vascular surgeons, interventional radiologists, podiatrists, and wound-care specialists should train together, not apart. Cross-disciplinary understanding fosters teamwork—and teamwork saves limbs.

Finally, continuing medical education and certification requirements should include mandatory PAD and CLI modules to ensure that practicing clinicians stay current with emerging techniques, evidence, and device technologies.

Education is equity. When every clinician is trained to recognize PAD early, manage it effectively, and know when to refer to a specialist, far fewer patients will ever face the devastating choice between amputation and walking on their own two feet.

But education and training alone aren’t enough if the rules that guide treatment and coverage lag behind innovation.

Aligning care through clinical guidelines and innovation access

Clinical guidelines are meant to bring consistency and accountability to care, ensuring that every patient receives evidence-based treatment regardless of where they live or which specialist they see. The Society for Vascular Surgery’s Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia (2019) remain a cornerstone in vascular care, emphasizing multidisciplinary decision-making and the importance of attempting to restore inline blood flow before considering amputation. Yet, like all guidelines, they could not anticipate every new technique or technology—particularly those emerging for small-vessel disease below the knee and into the foot.

The 2024 ACC/AHA Multisociety Guideline for the Management of Lower-Extremity PAD, endorsed by the Society for Vascular Surgery and other leading organizations, represents a long-awaited step toward unifying standards across vascular surgery, interventional cardiology, radiology, podiatry, and rehabilitation. It promotes team-based management, objective risk classification using tools like WIfI (Wound, Ischemia, and foot Infection), and more consistent care across specialties. Still, while it aligns broad practices, it stops short of requiring that every patient facing limb threat receive a documented attempt to re-establish blood flow below the knee or into the pedal arteries before amputation is approved.

That gap matters. “Attempt to restore flow” should not be a vague checkbox—it should be explicitly defined to reflect modern reality. Advanced revascularization now includes retrograde tibial and pedal access, tibial–pedal loop reconstruction, trans-collateral techniques, and, for patients who otherwise have no options, deep vein arterialization. Without that level of specificity, many patients still lose limbs simply because a physician doesn’t perform, believe in, or have access to these below-the-knee techniques—or because a hospital can’t spare the time or radiation exposure that complex limb salvage requires.

For clarity and accountability, the next generation of standards should require:

• Complete diagnostic imaging—angiography that includes tibial and pedal runoff to visualize foot circulation.
• A documented revascularization attempt—an effort to restore inline flow to the pedal arch when technically feasible, with reasons recorded when such attempts are not possible.
• CLI-specialist confirmation—a review or sign-off by a physician trained in critical limb-threatening ischemia before any non-emergent amputation proceeds.
• Post-procedure continuity—a structured plan for walking, rehabilitation, wound care, and surveillance to preserve durability.

Guidelines alone can’t close the access gap if insurers use outdated or selectively interpreted evidence to deny coverage for advanced therapies. That’s where policy mechanisms like Medicare’s Coverage with Evidence Development (CED) and the Transitional Coverage for Emerging Technologies (TCET) model come in. These frameworks allow provisional coverage for new, FDA-cleared treatments while real-world outcomes are gathered—striking a balance between innovation and accountability.

A strong example is deep vein arterialization, a technique that reroutes blood from veins into arteries to re-perfuse the foot when all other revascularization options have failed. In the PROMISE I study published in the Journal of Vascular Surgery, Dr. Daniel Clair and colleagues reported high technical success and an amputation-free survival rate of about 70 percent at twelve months among otherwise “no-option” patients. For someone whose only alternative is limb loss, denying access to such a therapy because it’s “not yet in the guidelines” borders on unethical.

To make the system work for patients, alignment is needed across three fronts:

• Guidelines that evolve in real time, jointly maintained by multiple societies so they reflect both evidence and innovation.
• Insurance policies that follow those evolving standards, rather than selectively applying outdated criteria to deny care.
• Hospitals equipped and staffed to meet them, with trained CLI specialists, radiation-safety protocols, and referral networks that prevent “we don’t do that here” from being an acceptable answer.

A patient’s chance to walk should never depend on which guideline their doctor follows, how busy an operating room schedule is, or whether an insurer finds the right paperwork language to deny care. It should depend on evidence, expertise, and empathy—and on a healthcare system that treats limb preservation as a moral and medical imperative, not an optional service.

Amputation Reduction: It takes all of us

Ending America’s amputation crisis will take more than laws, technology, or clinical guidelines—it will take alignment across every part of the healthcare ecosystem. Lawmakers, hospitals, insurers, physicians, advocacy groups, and patients themselves must move together toward one goal: preventing amputation before it happens and ensuring that no one faces this disease alone.

Federal action. Momentum is building in Washington. The Amputation Reduction and Compassion (ARC) Act, reintroduced in 2025, could become one of the most consequential pieces of legislation for limb preservation in decades. By requiring coverage for PAD screening across Medicare, Medicaid, and federal exchange plans, it would finally make early detection universal—catching disease while it can still be reversed through conservative treatment like walking therapy and medication. But legislation is only the starting point; patients also need clear pathways to care once they’re diagnosed.

Collective advocacy. Today’s advocacy landscape is fragmented—dozens of well-intentioned organizations operate in parallel, each offering pieces of the solution. But patients don’t live in silos, and they shouldn’t have to navigate one either. Real progress depends on unity. The goal isn’t to compete for attention or website clicks, but to ensure every person diagnosed with PAD has immediate access to legitimate education, evidence-based specialists, and actionable next steps.

That alignment doesn’t erase any organization’s identity—it amplifies their impact. National initiatives such as the Global PAD Association’s Leg Saver Hotline (1-833-PAD-LEGS) demonstrate what a coordinated model can look like: one trusted entry point that connects patients to the full ecosystem of credible resources, specialists, and advocacy groups nationwide. All legitimate sources—and all who choose to participate—can be represented and shared transparently, so when patients call, they gain access to every reputable option available. It democratizes access to care, ensuring visibility and trust for everyone working toward the same mission: saving limbs and saving lives.

Public awareness. PAD affects more Americans than most cancers combined, yet remains dangerously underrecognized. A national awareness campaign—jointly developed by advocacy organizations, medical societies, and industry partners—could transform outcomes by helping patients and primary care providers recognize symptoms earlier. But such efforts cannot be owned or branded by any one organization. To have the widest possible reach, awareness must be collaborative and noncompetitive, amplifying all voices equally under a shared message: amputation is not inevitable.

When legislation, advocacy, and awareness align, the system itself begins to heal. Each patient guided earlier into care becomes one less statistic. Each partnership built in good faith becomes one more bridge toward equity. Because in PAD, every delay costs more than tissue—it costs time, independence, and the chance to walk. And saving that chance will take all of us.

Hope on the horizon

Already, that alignment is beginning to take shape. Across the nation, bright spots are emerging—evidence that when collaboration meets courage, patients win.

In hospitals, cath labs, and research centers from Mississippi to Montana, forward-thinking physicians are redefining what’s possible for patients once told amputation was their only option. They’re navigating the smallest vessels in the foot, pioneering new access routes and techniques once thought impossible. Innovation, at last, is catching up to need.

Advocacy organizations are amplifying awareness, not in isolation but in collaboration. The more these groups work together, the clearer the message becomes: amputation is not inevitable. And in some corners of the healthcare industry, even insurance companies are starting to recognize that preventing amputations isn’t just good medicine—it’s good economics. Avoiding one unnecessary amputation saves not only a limb but also hundreds of thousands of dollars in long-term disability and wound care costs, while preserving a patient’s independence and dignity.

Most inspiring of all are the patients themselves. They are no longer silent, no longer accepting “there’s nothing more we can do” as an answer. Through the Global PAD Association’s Leg Saver Hotline (1-833-PAD-LEGS) and its network of clinicians and advocates, more than a thousand people have already avoided unnecessary amputations—finding specialists, navigating insurance appeals, and regaining their ability to walk.

Derek from Indiana, whose story opened this series, is one of them. After losing multiple toes to unnecessary amputations, he connected with a true limb-salvage specialist through the hotline. Today, he walks daily and now mentors others facing the same crossroads, showing that with the right care, recovery is not only possible—it’s sustainable.

These stories are more than individual victories; they are proof of concept. They show what happens when a system built on fragmentation begins to act in concert. When lawmakers remove barriers, insurers recognize value, hospitals invest in protection and training, while societies and advocacy groups unite, patients win—and lives change.

Every person deserves the chance to walk to live another day and live to walk another day. It’s time our healthcare system reflects that fundamental human right.

If you or a loved one faces PAD—especially if amputation has been recommended—seek a second opinion from a specialist trained in limb salvage. The decision you make could mean the difference between years of disability and a lifetime of mobility, independence, and hope. For immediate support, call the Global PAD Association’s Leg Saver Hotline at 1-833-PAD-LEGS or visit PADhelp.org.