AV Fistula
AV Fistula Creation is a vascular surgical procedure that constructs a direct connection between an artery and a vein in the arm — creating reliable, long-term haemodialysis access that provides the blood flow rates needed for effective dialysis with the lowest infection and complication rates of any access type.
Overview
AV Fistula Creation surgically joins an artery directly to a vein in the arm — most commonly the radial artery to the cephalic vein at the wrist (radiocephalic fistula) or the brachial artery to the cephalic vein at the elbow (brachiocephalic fistula) — causing the vein to dilate, develop a thickened muscular wall, and become capable of withstanding repeated large-bore needle access for haemodialysis three times per week. The native AV fistula is the preferred long-term dialysis access because it has the highest long-term patency, the lowest infection risk, and the lowest mortality compared to synthetic grafts or tunnelled catheters. Planning the fistula 3 to 6 months before expected dialysis start allows adequate maturation time.
Types of AV Fistula
The fistula configuration is selected based on vessel quality on pre-operative duplex mapping, the patient's vascular anatomy, and future vascular capital preservation.
- Radiocephalic (Brescia-Cimino) Fistula (wrist — gold standard, preserves proximal veins)
- Brachiocephalic Fistula (antecubital — for failed wrist fistula or inadequate forearm veins)
- Brachiobasilic Fistula (basilic vein superficialisation — for patients with no suitable cephalic vein)
- Forearm Loop Graft (PTFE synthetic graft — when native veins are exhausted)
- Brachial Artery to Antecubital Vein (elbow level for maximum inflow)
Risk Factors for Failed or Inadequate AV Fistula
Several patient factors affect the likelihood of successful fistula creation and maturation.
- Diabetes causing arteriosclerosis and reducing arterial inflow quality
- Obesity making forearm veins difficult to identify and access
- Previous arm vein cannulation damage from hospitalisation or drug use
- Peripheral vascular disease reducing arterial blood pressure at the wrist
- Previous central venous catheter causing subclavian or SVC stenosis limiting outflow
- Advanced age and female sex associated with smaller vessel calibre
End-Stage Renal Disease Symptoms Requiring AV Fistula
These clinical findings indicate the need for haemodialysis access planning and timely AV fistula creation.
- eGFR below 20 mL/min/1.73m² indicating likely need for dialysis within 12 to 18 months
- Rapidly declining kidney function predicting imminent dialysis requirement
- Uraemic symptoms beginning to develop despite conservative management
- Patient choice of haemodialysis over peritoneal dialysis as preferred modality
- Failed peritoneal dialysis requiring transition to haemodialysis
- Transplant failure requiring return to haemodialysis
- Patient referred for pre-emptive vascular access planning by nephrologist
- Previous fistula failure requiring new access creation at a different anatomical site
Key Benefits
Discover the advantages of choosing our av fistula services.
Immediate thrill confirmed in the operating room demonstrating successful fistula creation
Native AV fistula provides the highest long-term patency and lowest infection risk of all access types
Local or regional anaesthesia makes the procedure safe for patients with significant cardiac disease
Most fistula creations are day-case procedures with same-day discharge
Fistula matures over 6 to 12 weeks ready for first needle use providing years of reliable access
Clinical Features
The technology, techniques and clinical approach behind our av fistula.
Pre-operative duplex mapping confirms minimum vessel diameters before surgery is planned
Loupe magnification throughout vessel dissection and anastomotic suturing
Venous spatulation of 8 to 10 mm creates the funnel entry that maximises anastomotic flow
7-0 or 8-0 monofilament Prolene suturing achieves the finest possible vascular anastomosis
Immediate thrill confirmed by palpation and intraoperative Doppler before wound closure
Preparation Instructions
After AV Fistula Creation, protect your fistula arm from all compression — avoid blood pressure cuffs, tight clothing, sleeping on the arm, and carrying heavy bags. Feel for the thrill (buzzing sensation) twice daily and contact your vascular surgery team immediately if it disappears — early thrombosis within 48 to 72 hours is potentially salvageable. The fistula matures over 6 to 12 weeks before first needle use. Attend fistula maturation assessment with the renal access team at 6 to 8 weeks to confirm readiness for cannulation.
The Procedure
Step-by-step guide to what you can expect during your av fistula procedure.
Pre-Operative Duplex Vascular Mapping
Your vascular surgeon reviews the bilateral arm duplex map confirming radial artery diameter above 1.6 mm and cephalic vein diameter above 2.5 mm at the wrist — the minimum dimensions for a reliable radiocephalic fistula — before finalising the access site choice.
Local or Regional Anaesthesia
Local anaesthesia or brachial plexus block is administered providing excellent operative anaesthesia and immediate post-operative pain relief. Most patients remain awake and comfortable throughout — important given the cardiovascular comorbidities common in renal failure patients.
Wrist Incision and Vessel Identification
A small curved incision is made at the wrist overlying the radial artery and cephalic vein. Both vessels are carefully isolated for a length of 2 to 3 cm under loupe magnification — preserving all surrounding venous tributaries that contribute to fistula maturation flow.
Vessel Preparation and Spatulation
The cephalic vein is divided distally and spatulated on its posterior surface for 8 to 10 mm — creating the funnel-shaped venous opening that will form the end of the anastomosis. The radial artery is controlled with vascular bulldog clamps and a longitudinal arteriotomy is made.
End-of-Vein to Side-of-Artery Anastomosis
Using 7-0 or 8-0 monofilament Prolene, the spatulated vein end is sutured to the side of the radial artery arteriotomy with a continuous running technique — placing each suture under direct loupe magnification to achieve a completely watertight anastomosis without narrowing.
Thrill Confirmation and Wound Closure
Clamps are released and a strong palpable thrill is immediately confirmed over the anastomosis and along the outflow vein — confirming excellent fistula flow. The wound is closed with absorbable sutures and a light dressing applied. Discharge typically follows within 2 to 4 hours.
What to Expect
AV Fistula Creation is performed under local or regional (brachial plexus block) anaesthesia and takes 60 to 90 minutes. A small incision is made at the chosen access site, the artery and vein are identified, and an end-of-vein to side-of-artery anastomosis is created with fine vascular sutures under loupe magnification. A strong thrill (vibration) felt over the fistula immediately confirms excellent blood flow. Most patients go home the same day or after one overnight stay.
Frequently Asked Questions
Common questions about av fistula.
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