Severe ischemia of the upper extremity causing tissue necrosis occurs much less frequently than in the lower extremity. The clinical outcome of patients diagnosed with digital nonhealing ulcer or gangrene is largely unknown. A retrospective review of patients with upper extremity tissue loss was performed. Patients with ischemia from embolic disease, steal syndromes, and vasospastic or connective tissue disorders were excluded. Thirteen patients with upper extremity ischemic gangrene and/or nonhealing ulcers were treated from January 1995 to June 2002. Comorbid conditions included diabetes mellitus in 10 patients and renal failure in 11 patients. Five patients developed bilateral upper extremity ischemia during the period of evaluation, while 8 had unilateral involvement. Nine patients had dry gangrene of a digit, 5 had nonhealing ulcers, and 1 patient developed wet gangrene from an ischemic ulcer. All 13 patients received local wound care and medical treatment with anticoagulants, calcium channel blockers, or antiplatelet agents. Ischemic lesions healed in 3 of the 5 patients with conservative management. Surgical intervention was performed on 6 patients with dry gangrene, and the patient with wet gangrene underwent amputation of the hand (53.8%). Two patients underwent sympathectomy without improvement. In the remaining 3 patients, tissue loss remained stable. Seven patients died within 2 years of presentation with upper extremity ischemia, with a survival at 24 months of only 14% by lifetable analysis. The local outcome of severe upper extremity ischemia is generally favorable, with good response to either medical management or digit amputation. However, the life expectancy of the patients with upper extremity ischemia from true atherosclerotic disease is dismal. Therefore, surgical intervention should be reserved for infection control or pain relief only.