PURPOSE: Generally the steal syndrome occurs in proximal arterial-venous fistulas and only exceptionally with distal vascular access because of the high number of arteries supplying the hand. We describe a rare case of steal syndrome of a proximalized distal radio-cephalic fistula stealing from both the radial and ulnar artery through the palmar arch. METHODS: An 86 year old man was admitted because of a cyanotic, swollen left hand with trophic lesions at the third finger. He had a latero-terminal radio-cephalic fistula performed in 2006 with subsequent proximalization performed four years later after failure of the first one. Duplex ultrasound examination showed a high flow within the fistula (2080 mL/min) and a retrograde perfusion of the radial artery from the ulnar artery through the palmar arch and an angiography excluded stenosis along the radial artery. RESULTS: We treated the steal syndrome through a plication technique that was performed with careful flow variations measurement, under duplex evaluation, during the surgical procedure. That procedure was effective to maintain the fistula flow and obtain the symptoms relief. The patient was evaluated the day after the intervention and after 10 weeks. The clinical examination highlighted the resolution of hand ischemia. The Duplex Ultrasound examination showed a lower flow within the fistula (1060 mL/min) and a retrograde perfusion of the radial artery from the ulnar artery through the palmar arch with a three-phase flow. dialysis access from the fistula was never interrupted from immediately after surgery to the present date. CONCLUSIONS: Plication is an effective technique for treatment of steal syndrome requiring a short operative time and it is related to satisfying post-operative results.