ABSTRACT Objective: Dialysis access steal syndrome (DASS) is a serious limb-threatening complication of arteriovenous access for dialysis. Redirection of arterial inflow includes distal revascularization and interval ligation (DRIL) and revision using distal inflow (RUDI); both allow improvement of ischemic symptoms while preserving the access. Although outcomes with the DRIL are well established, experience with the RUDI for DASS remains promising. Aim of the work: The purpose of this study is to evaluate the efficacy and outcome of RUDI in comparison to DRIL in management of DASS. Methods: The present single centre randomized clinical study recruited 65 patients presented with DASS. A total of 40 patients presented with stage III and IV DASS during the study period. RUDI is performed in 19 patients and DRIL in 21 patients .The study was conducted at Vascular Surgery Departments, Zagazig University Hospitals-Egypt from May 2016 to January 2021. The primary outcome in the present study is clinical symptoms resolution and successful dialysis without pain. Other outcome parameters include duplex assessment of dialysis circuit flow rate and distal vessel PSV, complications, primary patency, assisted primary patency, secondary patency, cumulative primary and assisted primary patency as well as intervention free survival during 12 months follow up. Results: In DRIL group, patient demographics are as follows; mean age of 59.3 years, 16 females, 13 diabetics and 15 hypertensives, while in RUDI group; the mean age is 56.9 years, 13 females, 15 diabetics and 13 hypertensives. There are no preoperative differences in patient comorbidities between the RUDI and DRIL. Indications for intervention is tissue loss (30%) or ischemic rest pain (70%). Resolution of ischemic symptoms with successful dialysis without pain occurs in 89.5% of RUDI patients and in 85.7% of DRIL patients (P = 0.72), with regaining of radial pulsations. Ischemic rest pain persisted in two RUDI patients and three DRIL patients, those required access ligation to save the limb from progressive tissue loss. Two DRIL and three RUDI patients required partial or complete digital amputation after successful revascularisation. Primary patency between the RUDI and DRIL at 12 months (63.2% vs 61.9% ) are comparable (P = 0.99), as well as primary assisted patency at 12 months (73.7% vs 71.4% ; P = 0.87). Secondary patency between the RUDI and DRIL at 12 months (78.9% vs 76.2%) are also comparable (P = 0.83). Wound complications are documented in five patients (17%), including two DRILs and three RUDIs, all resolved with conservative management and antibiotics, Conclusion: RUDI is a good alternative to DRIL in managing of severe DASS symptoms and access preservation. RUDI avoids DRIL's complexity and risks with similar symptom resolution, patency, and complication rates.