A 58-year-old male with end-stage kidney disease secondary to diabetic nephropathy has been receiving hemodialysis (HD) since 2021 via a left brachiocephalic arteriovenous fistula (AVF). He presented to our center with persistent, severe pain and discoloration of the left fifth finger. (Figure1). Vascular access ultrasound revealed a brachial artery blood flow rate of 800mL/min, with the presence of a collateral outflow tract. (Figure 2A) Based on physical examination and ultrasound findings, he was diagnosed with hemodialysis access-induced distal ischemia (HAIDI) stage 4b.. Notably, there was extensive calcified atherosclerotic plaque within the brachial artery, located 5cm downstream from anastomosis. (Figure2B and 2C). Due to insufficient outflow, we prioritized improving inflow by planning a brachial artery endarterectomy (Figure 3) targeting the atherosclerotic plaque as visualized on vascular ultrasound. One month later, we performed a graft transposition from cephalic vein to axillary vein to improve the outflow tract. Six months later, he underwent a left fifth finger Volar V-Y advancement flap procedure in the orthopedic department. His persistent, severe pain dramatically subside and the color change in his hand improved significantly. (Figure 4A) In addition, vascular access ultrasound demonstrated complete resolution of the atherosclerotic plaque with improved blood flow (Figure 4B and 4C) In conclusion, HAIDI is a major complication following vascular access creation and has historically been challenging to manage without compromising access. In cases of HAIDI stage4b, management may require ligation in extreme cases of distal gangrene and ulceration In the contralateral extremity, severe brachial artery calcification suggests that even if the left dialysis access arm is ligated and access is re-established on the opposite side, HAIDI may recur. Therefore, when focal atherosclerotic plaque is present in the inflow brachial artery, brachial artery endarterectomy may be considered to improve blood flow.