A 61-year-old man presented to a clinic with the complaint of 6 weeks of right middle finger pain and swelling. His medical history included type 2 diabetes mellitus, hypertension, peripheral arterial occlusive disease, and chronic kidney disease. The patient received dialysis through an arteriovenous fistula in his right arm. The right middle finger became gangrenous after 8 weeks (image A). Postpresentation arteriogram records indicated steal syndrome causing vascular insufficiency in all right hand digits (image B). The right middle finger autoamputated a few weeks later. Hemodialysis is a common risk factor for ischemia of the upper extremity, and amputation is a common sequelae. 1 Studies have shown that currently the best management of dialysis-associated steal syndrome is distal revascularization with interval ligation, which involves ligating an artery distal to the fistula and subsequently forming a bypass. 2 Owing to the high mortality rates of dialysis patients who require upper extremity amputations, early revascularization efforts are key. 3 (doi:10.7556/jaoa.2018.166) References 1. Ferraresi R, Acuña-Valerio J, Ferraris M, et al. Angiographic study of upper limb vascularization in a large cohort of hemodialysis patients with critical hand ischemia. Minerva Cardioangiol. 2016;64(6):642-647. 2. Regalado S, Navuluri R, Vikingstad E. Distal revascularization and interval ligation: a primer for the vascular and interventional radiologist. Five-year mortality for patients with end-stage renal disease who undergo upper extremity amputation. J Hand Surg Am. 2015;40 (4):666-672.