Background Aboriginal and Torres Strait Islander Peoples are at high risk of developing peripheral artery disease (PAD), having poor outcomes and a high rate of major amputation. Anecdotally, these patients are predisposed to distal arterial disease, but whether this distribution of disease is unique compared to non-Indigenous patients is unknown. This study compared the distribution and severity of PAD in Aboriginal and Torres Strait Islander and non-Indigenous patients. Methods A retrospective cohort study was conducted with patients who underwent lower-limb revascularisation between January-2015 and July-2023. Clinical and angiographic PAD severity was assessed at the time of first presentation to the vascular surgery service. Rutherford classification was used to clinically assess PAD severity, where 1-3 indicated degrees of intermittent claudication (IC), whilst 4-6 indicated degrees of chronic limb threatening ischaemia (CLTI). Three validated angiographic scoring systems (GLASS, ANGIO-score, TASC) were used to assess angiographic PAD severity based on computer tomography and digital subtraction angiography. Results 504 patients were included. 57 (11.3%) were Aboriginal and Torres Strait Islander, who were more likely to present with CLTI (74% vs 65%, p=0.01) than IC compared to non-Indigenous patients. No Aboriginal and Torres Strait Islander patient presented with rest pain without tissue loss. They were more likely to present with infrapopliteal disease (GLASS: OR 1.93, 95%CI 1.15-3.24; ANGIO-score: OR 1.97, 1.18-3.29; p=0.01), but less likely to present with aortoiliac disease (TASC: OR 0.36, 0.18-0.72, p=0.004; ANGIO-score: OR 0.39, 0.20-0.76, p=0.006) compared to non-Indigenous patients. Conclusion Aboriginal and Torres Strait Islander Peoples are more likely to present with more severe PAD clinically, with a predisposition for infra-popliteal artery disease. Investigation into how best to treat tibial disease in this cohort is essential to improving PAD outcomes.