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Two patients with scleroderma, ischemic pain, non-healing digital ulceration, and digital arterial obstruction were successfully treated with peripheral sympathectomy and digital arterial reconstruction using a reversed small-caliber vein graft. Postoperatively, digital blood flow increased and ulceration healed in both patients. Peripheral sympathectomy alone may not adequately improve digital perfusion, when the benefits of decreased vasospasm are offset by the presence of digital arterial insufficiency. When technically feasible, digital arterial reconstruction improves digital blood flow in scleroderma patients in whom digital collateral circulation appears inadequate after sympathectomy.