Introduction: Vascular access-related hand ischaemia (ARHI), also known as steal syndrome, is a complication of arteriovenous fistulas for haemodialysis. This study evaluates management strategies and outcomes of patients with ARHI in the contemporary Australian vascular surgery setting. Methods: A retrospective review was conducted on patients diagnosed with ARHI between 2017 and 2024, in two tertiary centres in Victoria. Data collected included demographics, medications, grade of steal, fistula configuration, volume flow, and operative details. Outcomes assessed were symptom resolution, digital amputation, and fistula preservation. Results: A total of 59 patients were included. The mean age was 59, with a male-to-female ratio of 1.2. Most patients had a brachiocephalic fistula (53%) and presented with grade 4 steal syndrome. Common procedures were fistula ligation (33%) and AVF banding (28%). Symptom resolution was achieved in 61% of patients, while 16% required digital amputation. The fistula was preserved in 68% of cases. Significant predictors for symptom resolution included anticoagulation therapy and grade 2 and 3 steal. The presence of tissue loss or grade 4 steal, and ischaemic heart disease were associated with a higher risk of digital amputation (p<.05). High flow steal (>1500 ml/min) showed a lower risk of digital amputation and greater chance of fistula preservation, though not statistically significant. Conclusion: Management of ARHI requires a tailored approach based on symptom severity and fistula characteristics. This study highlights the importance of early detection and appropriate intervention to prevent digital loss. Adherence to guidelines, including surveillance and timely intervention, is crucial in optimising outcomes. Future studies should focus on refining surveillance protocols and identifying predictive factors for better outcomes in steal syndrome.