Among 10,666 Medicare beneficiaries with chronic limb-threatening ischemia undergoing major lower-extremity amputation, 16.6% received no vascular imaging beforehand, with 9.4% receiving no specialist evaluation, imaging, or revascularization attempts. Patients most likely to skip evaluation had dementia, paralysis, or dual Medicare-Medicaid eligibility rather than extreme medical complexity. Regional variation was striking—Boston and Atlanta had only 3% non-evaluation rates versus 16% in Little Rock. This finding exposes concerning gaps in guideline-adherent care for vulnerable populations. Chronic limb-threatening ischemia represents the most severe form of peripheral artery disease, affecting millions of Americans and often leading to amputation when blood flow cannot be restored. Current guidelines universally recommend vascular specialist consultation and revascularization attempts before considering major amputation, as limb salvage procedures can often preserve function and quality of life. The study reveals that cognitive impairment and socioeconomic disadvantage—rather than medical unsuitability—drive evaluation gaps, suggesting these patients may be undertreated due to perceived futility rather than actual contraindications. However, this preprint awaits peer review, and the observational design cannot establish whether evaluation gaps represent appropriate clinical judgment or care disparities requiring intervention.