Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Secondary hemodialysis arteriovenous fistula

Gerald A Beathard, MD, PhD
Section Editors
David L Cull, MD
Jeffrey S Berns, MD
Deputy Editor
Kathryn A Collins, MD, PhD, FACS


Among the three principal forms of chronic vascular access available for hemodialysis, the arteriovenous (AV) fistula is most desirable because it has the best long-term primary patency rate, requires the fewest interventions, and is associated with the lowest morbidity and mortality when compared with the alternatives [1-5]. The rationale for the preference of an AV fistula rather than other forms of hemodialysis access is discussed separately. (See "Overview of chronic hemodialysis vascular access" and "Arteriovenous fistula creation for hemodialysis and its complications", section on 'Infection'.)

We agree with Fistula First Breakthrough Initiative (FFBI) Change Concept #3 that every potential hemodialysis patient should be first evaluated for an AV fistula [6], which has become the standard for clinical practice. In spite of this initiative, approximately 30 percent of patients receiving hemodialysis in the United States do so with an AV graft, which may be appropriate under some circumstances, such as in the patient without any suitable vessels or the patient with a limited life expectancy (ie, palliative dialysis) [1].

Any patient using an AV graft should also be considered a potential candidate for conversion to an AV fistula if the graft fails, which is referred to as a secondary arteriovenous fistula (SAVF). This is defined as an AV fistula that is created following the failure of a previous AV access (generally lower arm) and includes either an AV graft (most commonly) or an AV fistula.

The options, evaluation of the patient, and choice of secondary hemodialysis access are reviewed here. Primary hemodialysis AV access, including maturation and initial management of failed primary AV access, is discussed separately. (See "Maturation and evaluation of the newly created hemodialysis arteriovenous fistula" and "Primary failure of the hemodialysis arteriovenous fistula".)


The concept of a secondary arteriovenous fistula (SAVF) is very important, given the known issues and complications associated with arteriovenous (AV) fistulas and, to an even greater extent, AV grafts. In the past, a SAVF was defined as an AV fistula constructed using the outflow vein of an AV graft. The definition has been expanded to include any AV fistula constructed following the failure of a prior AV access, regardless of whether the primary access was an AV fistula or AV graft. Two types of SAVF are defined. Although both are referred to as an SAVF, they differ conceptually. Each is described below.

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Apr 17, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Lynch JR, Wasse H, Armistead NC, McClellan WM. Achieving the goal of the Fistula First breakthrough initiative for prevalent maintenance hemodialysis patients. Am J Kidney Dis 2011; 57:78.
  2. McClellan WM, Wasse H, McClellan AC, et al. Treatment center and geographic variability in pre-ESRD care associate with increased mortality. J Am Soc Nephrol 2009; 20:1078.
  3. Ravani P, Spergel LM, Asif A, et al. Clinical epidemiology of arteriovenous fistula in 2007. J Nephrol 2007; 20:141.
  4. Huijbregts HJ, Bots ML, Wittens CH, et al. Hemodialysis arteriovenous fistula patency revisited: results of a prospective, multicenter initiative. Clin J Am Soc Nephrol 2008; 3:714.
  5. NKF-K/DOQI Clinical Practice Guidelines For Vascular Access: Update 2006. Guideline 8: Clinical outcome goals, 8.1 goals for access placement, 8.1.2 prevalent functional AVF placement rate. http://www2.kidney.org/professionals/KDOQI/guideline_upHD_PD_VA/ (Accessed on November 22, 2016).
  6. Fistula First Catheter Last. http://esrdncc.org/ffcl/change-concepts/ (Accessed on June 01, 2015).
  7. Beathard GA. Interventionalist's role in identifying candidates for secondary fistulas. Semin Dial 2004; 17:233.
  8. Spergel LM, Ravani P, Asif A, et al. Autogenous arteriovenous fistula options. J Nephrol 2007; 20:288.
  9. Asif A, Unger SW, Briones P, et al. Creation of secondary arteriovenous fistulas: maximizing fistulas in prevalent hemodialysis patients. Semin Dial 2005; 18:420.
  10. Beathard GA. Strategy for maximizing the use of arteriovenous fistulae. Semin Dial 2000; 13:291.
  11. Slayden GC, Spergel L, Jennings WC. Secondary arteriovenous fistulas: converting prosthetic AV grafts to autogenous dialysis access. Semin Dial 2008; 21:474.
  12. Oliver MJ, McCann RL, Indridason OS, et al. Comparison of transposed brachiobasilic fistulas to upper arm grafts and brachiocephalic fistulas. Kidney Int 2001; 60:1532.
  13. NKF-K/DOQI Clinical Practice Guidelines For Vascular Access. Clinical Practice Guideline 2: Selection and placement of hemodialysis access, 2.1 the order, 2.1 . 4 Patients should be considered for construction of a primary AVF after failure of every dialysis AV access. Am J Kidney Dis 2006; 48(Suppl 1):S248.
  14. Sidawy AN, Spergel LM, Besarab A, et al. The Society for Vascular Surgery: clinical practice guidelines for the surgical placement and maintenance of arteriovenous hemodialysis access. J Vasc Surg 2008; 48:2S.
  15. Nguyen VD, Treat L, Griffith C, Robinson K. Creation of secondary AV fistulas from failed hemodialysis grafts: the role of routine vein mapping. J Vasc Access 2007; 8:91.
  16. LoGerfo FW, Menzoian JO, Kumaki DJ, Idelson BA. Transposed basilic vein-brachial arteriovenous fistula. A reliable secondary-access procedure. Arch Surg 1978; 113:1008.
  17. Cantelmo NL, LoGerfo FW, Menzoian JO. Brachiobasilic and brachiocephalic fistulas as secondary angioaccess routes. Surg Gynecol Obstet 1982; 155:545.
  18. Dunlop MG, Mackinlay JY, Jenkins AM. Vascular access: experience with the brachiocephalic fistula. Ann R Coll Surg Engl 1986; 68:203.
  19. Nazzal MM, Neglen P, Naseem J, et al. The brachiocephalic fistula: a successful secondary vascular access procedure. Vasa 1990; 19:326.
  20. Jennings WC. Creating arteriovenous fistulas in 132 consecutive patients: exploiting the proximal radial artery arteriovenous fistula: reliable, safe, and simple forearm and upper arm hemodialysis access. Arch Surg 2006; 141:27.
  21. Salman L, Alex M, Unger SW, et al. Secondary autogenous arteriovenous fistulas in the "fistula first" era: results of a longterm prospective study. J Am Coll Surg 2009; 209:100.
  22. Ascher E, Hingorani AP, Yorkovich WR. Techniques and outcomes after brachiocephalic and brachiobasilic arteriovenous fistula creation. In: Dialysis access: A multidisciplinary approach, Gray RJ, Sands JJ (Eds), Lippincott Williams & Wilkins, Philadelphia 2002.