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Creating an arteriovenous fistula for hemodialysis

Gerald A Beathard, MD, PhD
Section Editors
Jeffrey S Berns, MD
John F Eidt, MD
Joseph L Mills, Sr, MD
Deputy Editor
Kathryn A Collins, MD, PhD, FACS


The three principal forms of chronic vascular access for hemodialysis are native arteriovenous (AV) fistulas, AV grafts, and tunnelled double-lumen catheters. Of these, the native AV fistula is preferred for long-term hemodialysis vascular access since it has the best long-term primary patency rate, requires the fewest interventions of any type of access, and, most importantly, is associated with the lowest incidence of morbidity and mortality [1-5]. The National Kidney Foundation Kidney Disease Quality Outcomes Initiative (NKF-KDOQI) clinical practice guidelines suggest a goal prevalence rate for native AV fistulas of 65 percent [6]. To achieve these goals, disparities in the successful creation of native AV fistulas need to be overcome. In most studies, fewer AV fistulas are reported in female than in male hemodialysis patients [7-11] and in African-American compared with non-African-American hemodialysis patients [7-12]. The explanation for gender and racial differences is not totally clear; however, it has been shown that there is a greater risk of primary failure in both women and African Americans [13,14].

The creation of native AV fistulas for hemodialysis patients is reviewed here. An overview of the different types of chronic hemodialysis access is presented separately. (See "Overview of chronic hemodialysis vascular access".)


The constant goal for arteriovenous (AV) hemodialysis access should be to increase AV fistula prevalence since AV fistulas provide patients with end-stage renal disease (ESRD) with a dialysis access with the lowest morbidity and mortality and best long-term patency. The basic principle is that a well-functioning fistula is always better than the alternative [15-20], although there are some reports that do not agree [21,22].

Benefits — Arteriovenous (AV) fistulas are preferred over other forms of chronic hemodialysis access, and we recommend placement of an AV fistula rather than an AV graft or tunnelled double-lumen central catheter whenever possible. However, the temptation to create an AV fistula to satisfy the fistula-first initiative in patients with inadequate vessels should be resisted. Overly aggressive attempts to increase AV fistula prevalence in patients with suboptimal anatomy leads to reduced maturation rates and a longer duration of dialysis catheter use [23]. (See "Patient evaluation and vascular mapping prior to placement of hemodialysis arteriovenous access", section on 'Ideal type of hemodialysis AV access'.)

The benefits of AV fistulas over other forms of chronic access are summarized below and discussed in detail elsewhere. (See "Overview of chronic hemodialysis vascular access", section on 'Comparison of AV fistulas and AV grafts'.)


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Literature review current through: Jul 2017. | This topic last updated: May 19, 2017.
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