Several disease pathways lead to chronic ischemia of the hand. The end-result is severe pain and eventually tissue necrosis. Treatment options have generally been limited to sympathectomy with or without arterial reconstruction. In the absence of significant digital blood flow or a reconstructable arterial system, these treatments will not improve tissue perfusion. Arterialization of the venous system is a procedure first proposed at the beginning of the last century as an alternative means of providing arterial blood flow to ischemic tissues. This salvage technique is used when there is no way to restore antegrade arterial flow. A patient with end-stage renal disease and severe ischemic hand pain underwent division of the cephalic vein with end-to-side anastomosis of the distal vein to the radial artery. Multiple side branches of the vein were ligated to direct flow to the hand. The patient experienced significant reduction in pain and healing of ischemic wounds. Since then arterialization of the venous system of the hand has been performed on four hands in three patients, with similarly favorable results. The indications, technique and results of this procedure will be presented.