Objective: Access-related hand ischemia (ARHI) is a potentially limbthreatening complication of arteriovenous access for dialysis. The distal revascularization-interval ligation (DRIL) and revision using distal inflow (RUDI) procedures both allow treatment of ischemic symptoms while maintaining fistula patency. Although outcomes with the DRIL are well established, experience with the RUDI for ARHI remains preliminary. We compared outcomes in these procedures with respect to cumulative patency, resolution of symptoms, and patient survival.Methods: A large, prospectively maintained database was used to identify all patients after autogenous arteriovenous fistula construction at two hospitals between 2005 and 2015. Patients with severe (Society for Vascular Surgeons grade 3) ARHI were included for analysis.Results: A total of 2035 autogenous accesses were created during the study period, and 58 (2.8%) developed grade 3 ARHI. Of this cohort, 20 patients underwent RUDI and 21 had a DRIL. The indication for intervention was tissue loss (61%) or ischemic rest pain (39%). Mean age was 57.5 years, and 53.7% of patients were female. Most patients had diabetes (85.3%) and symptomatic peripheral arterial disease (63.4%). The mean digital-brachial index was 0.25 6 0.12. There were no preoperative differences in patient comorbidities between the RUDI and DRIL cohorts. Twelvemonth primary patency (60% vs 67.7%; P ¼ .658) and secondary patency (85% vs 90.5%; P ¼ .592) were similar between groups. Three-year primary patency (55% vs 52.4%; P ¼ .867) and secondary patency (80% vs 90.5%; P ¼ .343) also showed no significant difference. Resolution of ischemic symptoms, including resolution or improvement in pain or healing of ischemic ulcers or amputations, occurred in 90% with RUDI and in 81% with DRIL (P ¼ .131). Survival for the RUDI and DRIL groups at 1 and 3 years was 85% vs 85.7% (P ¼ .948) and 57.9% vs 49.2% (P ¼ .278).Conclusions: Compared with DRIL, RUDI demonstrated equivalent patency, symptom resolution, and survival for the treatment of severe ARHI. Given the poor long-term survival, preoperative risk assessment is critical to procedural decision making.