Pain and swelling of the fingers and hand and digital ulceration occurred in two patients on maintenance hemodialysis who had conventional side-to-side, arteriovenous shunts. Proximal cephalic vein occlusion with distal diversion of shunt flow through dilated, tortuous veins was demonstrated by brachial arteriography. In both instances, closure of the shunt resulted in immediate relief of symptoms. Based on the pathogenesis of this complication, an end-to-side, vein-to-artery shunt has been advocated. Comparative advantages of the technique as described include ease of performance, suitability for small-caliber veins, effective dilation by hydrostatic distention, and earlier postoperative utilization of the shunt.