Section: Arteriovenous Fistula Planning and Decision-Making 
Jerry Svoboda, Richard Davis 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Background:  
 
In very poor countries, options for chronic 
renal insufficiency are few. As a country advances 
economically however, penetration of hemodialysis 
will increase. The surgeon will be called on to place 
temporary or permanent dialysis catheters and to 
create arteriovenous fistulas.  
The basic principle of an arteriovenous 
fistula is this: when a vein is subjected to arterial 
blood flow, it dilates and its wall becomes thickened. 
Such a fistula should have enough blood flow to 
permit rapid withdrawal and replacement of blood 
during hemodialysis (350-800mL/minute.) The 
thickened walls are able to withstand repeated 
venipuncture. If such a vein is near enough to the 
skin, it can be repeatedly accessed by a non-
physician for hemodialysis. Reaching this condition 
takes at least 6 weeks, sometimes several months.  
Decision 
on 
criteria 
for 
long-term 
hemodialysis is generally not the purview of the 
surgeon. (Conversely, the surgeon must be well 
aware of the criteria for short term dialysis in case of 
acute kidney injury. Briefly, they are acidosis, 
volume overload, uremia, hyperkalemia and need for 
clearance of toxins.) 
 
Anatomy:  
 
The arm is preferred over the leg for fistula 
creation. Whereas the arterial anatomy of the arm 
varies only rarely, the venous anatomy is highly 
variable. 
 
The brachial artery in the upper arm runs within the muscle 
fascia. It is covered by the bicipital aponeurosis, a band of 
fibrous tissue that runs between the biceps and the pronators 
and flexors of the wrist. This structure must be divided to access 
the artery at the level of the elbow. Though the median nerve 
runs just medial to the artery, it is most often not seen during 
fistula surgery. Injury to this structure is unlikely with careful 
dissection. The ulnar nerve runs posteromedial to these 
structures, and is vulnerable to injury during careless 
dissection of the basilic vein.  
 
Section: Arteriovenous Fistula Planning and Decision-Making 
Jerry Svoboda, Richard Davis 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
The radial artery is palpable in the distal forearm before it 
passes under the extensors and abductors of the thumb to 
anastomose with the ulnar artery via the palmar arch. It is not 
palpable proximal to the mid forearm, and more difficult to 
access, as it passes underneath the brachioradialis muscle.  
 
 
The anatomy of the superficial venous system of the arm is 
highly variable; one possibility is shown here. The cephalic and 
basilic veins in the upper arm are constant. A median 
antecubital vein is often present, connecting to the cephalic 
vein. The cephalic vein running along the radial side of the 
forearm is usually present.  
 
 
Section: Arteriovenous Fistula Planning and Decision-Making 
Jerry Svoboda, Richard Davis 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Principles:  
 
There are two possibilities for fistula 
creation: Arteriovenous fistula, the direct connection 
of a vein to an artery, and arteriovenous graft, the 
connection of an artery to a vein by a prosthetic 
conduit. The prosthetic material, if used, is usually 
polytetrafluoroethylene (PTFE, various brands.) 
Fistulas are most commonly connected end-vein to 
side-artery. Grafts are connected end-graft to side-
artery and side-vein. When used, the graft is 
configured either straight in the forearm or upper 
arm, or as a loop in the forearm. Infection of the graft 
mandates removal, but it is unclear whether such 
infections occur more frequently in resource-limited 
settings such as ours.  
Arteriovenous fistulae are generally placed in 
four common locations: 
● Distal radial-cephalic: the end of the cephalic 
vein is anastomosed to the side of the radial 
artery at the wrist. This fistula has perhaps the 
lowest success rate of all due to the frequently 
small size of the vein here. However, it can be 
done under local anesthesia and if it fails, another 
fistula can be attempted more proximally in the 
arm. The converse is not true: if a proximal 
fistula has failed, a more distal one is unlikely to 
succeed. Another advantage to this fistula is that 
in >95% of patients, the hand will remain viable 
even if the radial artery is irreversibly damaged 
through surgical misadventure, because of the 
ulnar artery and the palmar arch. Similarly, “steal 
syndrome,” the loss of perfusion to the distal arm 
due to excessive flow through the fistula, occurs 
only rarely. Creation of a wrist level AVF is 
advised if the vein is adequate, as patients on 
long-term dialysis need as many possible fistula 
sites preserved as possible.  
● Proximal radial-cephalic: the end of the cephalic 
vein is anastomosed to the side of the radial 
artery in the forearm. This operation is practical 
up to the mid-forearm, though the radial artery is 
deeper than at the wrist. It is a useful option if 
veins in this area are large, and it does not prevent 
a fistula based on the brachial artery later. The 
advantages of radial artery fistula described 
above also apply here.  
● Brachial-cephalic: The end of the cephalic or 
lateral antebrachial cutaneous vein is attached to 
the side of the brachial artery. This operation is 
technically easy to perform; all the vessels 
involved are relatively large and superficial. The 
major disadvantage is the potential for steal 
syndrome. Patients may experience coldness, 
numbness, or severe pain, either during dialysis 
or during use of the hand. This complication is 
best prevented by limiting the size of the 
arteriotomy to 6mm.  
● Brachial-basilic: The end of the basilic vein is 
attached to the side of the brachial artery. The 
basilic vein runs deep to the fascia of the upper 
arm and is therefore unsuitable as a fistula unless 
it is superficialized. This is commonly done by 
dissecting it out along its length from the elbow 
to the axilla, and then transposing it to the 
anterior midline of the upper arm, where it is 
more accessible for dialysis. This transposition 
can be done in one or two stages, as described in 
the Chapter on this operation.  
 
Decision Making: 
 
The surgeon must evaluate the patient very 
carefully and select a location where the fistula has 
the best chance of success. The patient should 
understand that fistulas are generally not permanent, 
so part of the planning includes considering future 
fistula locations and the effect that any present one 
will have. The following general principles apply:  
● Patients will generally prefer a fistula on their 
non-dominant arm, though the surgeon should 
prefer this side only if the veins and arteries are 
of otherwise equal quality on both sides. 
● The surgeon should consider the position that the 
arm will be in during dialysis; even a paralyzed 
or contracted arm is acceptable as long as a 
fistula on it can be accessed while the patient is 
seated comfortably.  
● Fistulas will generally have at least a 10% initial 
failure rate, even if made perfectly with excellent 
quality vessels. The most meticulous attention to 
detail is needed to assure the highest chance of 
success! 
● When a distal fistula fails, one can be placed 
more proximally. However, when a proximal 
fistula fails, a subsequent more distal one is 
usually unsuccessful.  
Section: Arteriovenous Fistula Planning and Decision-Making 
Jerry Svoboda, Richard Davis 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
● Fistulas with veins smaller than 2.5mm diameter 
often fail immediately. Those with veins smaller 
than 3mm diameter may have prolonged 
maturation times, even if they remain patent.  
● Veins that have been repetitively traumatized are 
less useful for a durable fistula. Once a fistula site 
is chosen, the patient should receive no further 
blood draws or IV’s on that side. Once the fistula 
has been placed, IV’s, blood draws, and blood 
pressure checks on that side are strictly 
forbidden.  
 
The patient’s arterial and venous system are 
carefully evaluated by physical examination, 
supplemented with ultrasound.  
 
A venous ultrasonography chart such as this one can be used 
by the ultrasonography staff to document the sizes and patency 
of the veins. 
 
 
The patient’s radial and brachial pulses are 
evaluated. A feeble radial pulse should not be used. 
A patient with diabetes may have a calcified radial 
artery, which is hard to the touch. These will be very 
difficult to use for fistula formation.  
 
A phlebotomy tourniquet is then placed 
around the upper arm and the arm is allowed to hang 
below the level of the patient’s bed or chair. The 
superficial venous system can be assessed: patent 
veins should be palpable but compressible, whereas 
thrombosed veins will be noncompressible. The 
patient may squeeze and release their fist, or squeeze 
a rubber ball, to increase vein distention.  
 
The veins and arterial pulsation can be 
marked for decision making. The surgeon should 
assess the superficial veins for the following:  
● Compressibility: does the vein in question seem 
thrombosed, or otherwise in poor shape? Healed 
scars above the vein may indicate previous 
trauma. Visible venous valves are a normal 
finding; the vein can still be used.  
● Length: can enough vein be mobilized to reach 
the arterial pulsation? Are there large branches 
that must be ligated in order to do so?  
● Size: does the vein seem to be at least 3mm in 
size? Be sure to give the veins a fair assessment: 
they will consistently get larger the longer that 
the arm has been hanging off the side of the bed 
or chair with the tourniquet in place.  
 
Section: Arteriovenous Fistula Planning and Decision-Making 
Jerry Svoboda, Richard Davis 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
Examination of the radial artery. The surgeon palpates with the 
index finger, moving up and over the bone into the recess 
adjacent to it, feeling for the pulsation of the radial artery.  
 
 
The same right arm (previously marked for surgery,) hanging 
over the side of the bed, immediately after application of the 
tourniquet (left) and after two minutes (right.) The longer after 
the tourniquet has been applied, the more visible the veins will 
be, so wait a while before concluding that there aren’t any 
usable options. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Jerry Svoboda, MD FACS 
Rochester, New York 
USA 
 
Richard Davis, MD FACS FCS(ECSA) 
AIC Kijabe Hospital 
Kenya 
Resource-Rich Settings 
Arteriovenous fistula creation is open surgery in Resource-
Rich settings as well. One difference, however, is the 
availability of percutaneous radiological interventions to 
salvage a thrombosed fistula, which can extend its lifetime.  
 
Peritoneal dialysis has been used successfully in the short 
term in resource-limited settings. But it has not been adopted 
as well in the long term, because of the need for complex 
dialysis solutions and the severe complications of sclerosing 
peritonitis. 
 
The biggest difference in Resource-Rich settings is the 
availability of renal transplantation. In fact, in patients whose 
renal failure will occur at a predictable time, renal 
transplantation can be used to avoid dialysis altogether.  
