Digital ischemia and cold sensitivity after replantation are common. Occasionally they are severe enough to warrant intervention, including amputation of an otherwise functional digit. We present a patient with pregangrenous ischemia in a replanted thumb 10 years after multiple digit replantation. Angiography revealed vascular occlusion in the distal radial artery with no patent vessel in the thumb. The option of transposition of a spare neurovascular bundle from the adjacent radial digits was limited by their single-vessel supply resulting from previous replantation. We describe a method of revascularization by introduction of an arteriovenous pedicle, using a free fascial flap harvested from the lateral arm and based on terminal ramifications of the profunda brachii vessels. The flap was buried between the pulp and flexor tendon sheath and anastomosed to the radial artery and a wrist vein. This resulted in successful revascularization of the digit, clinically and radiologically, and 20 months later, the patient remains symptom free.