Direct arterial bypass remains the best option in patients with terminal ischemia of the hand, if there is an adequate distal target vessel. In situ bypass is the procedure of choice in patients who are candidates for arterial bypass. Venous arterialization offers an option in patients in whom there is not adequate arterial runoff in the hand. Venous arterialization should be avoided in patients with significant wounds and/or active infection. In selected patients, microvascular omental transfer can offer an option for revascularization of the ischemic hand.