The hemodialysis patient requires continued attention once an access surgery has been performed. These procedures lead to an anticipated physiological steal in the involved hand, but rarely lead to hand loss. When the patient has had previous peripheral vascular disease, known diabetes mellitus, multiple interventions on the same extremity, and the use of a synthetic graft, the incidence of digital or hand ischemia is significantly increased. This article represents 3 individuals who required hand amputation for severe ischemia. The pertinent clinical features in each individual will be explained and the literature reviewed for the factors promoting this complication and the all-autogenous access policies which may help to prevent hand ischemia.