Introduction Duplex ultrasound is a valuable modality for the assessment of hemodialysis access function. A potential complication of hemodialysis access is arterial steal, which occurs when venous outflow exceeds the capacity of the inflow artery, and flow in this distal artery becomes retrograde, stealing blood flow from the hand to the fistula site. A potential condition resulting from arterial steal is hand or digit ischemia. Distal revascularization-interval ligation (DRIL) procedures can be used to “bypass” the fistula or graft site and deliver blood to the hypoperfused hand. Presented is a case of an arterial steal with severe hand ischemia that was alleviated by a DRIL procedure. Case Study A 69-year-old woman presented to the vascular laboratory with an ischemic right hand and digital ulcer distal to a brachial-axillary arteriovenous graft (AVG). Duplex ultrasound was performed of the right upper-extremity inflow arteries, AVG, and outflow veins. Ipsilateral brachial, radial, and ulnar artery waveform analysis for direction of flow was performed with and without AVG compression. The evaluation revealed significant arterial ischemia that returned to normal after manual compression of the AVG. The patient underwent a DRIL procedure after the pre-op duplex evaluation. Postprocedural duplex evaluation revealed patent inflow and outflow vessels, patent graft, and bypass (DRIL) with antegrade flow in the brachial and radial arteries and no change of flow with manual graft compression; clinically, the patient had a healing ulceration of the digit. Conclusion Duplex ultrasound for hemodialysis access should not only be used to evaluate for patency of the fistula or graft but should include assessment for ischemia and/or steal. This case demonstrates the importance of the assessment of the distal arterial segments including digital waveforms, and the use of manual compression to complete the hemodialysis access evaluation. DRIL procedures can potentially correct arterial steal while preserving access function.