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An autologous arteriovenous fistula (AVF) is a surgically created direct connection between an artery and a vein (without prosthetic material), most often in the upper limb, to provide reliable vascular access for long-term hemodialysis.

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It is the preferred vascular access for end-stage renal disease patients due to its durability, high patency rates, and low infection risk compared to synthetic grafts or central venous catheters.

My arm cut open while I was having a fistula built in case I ever needed dialysis

https://www.reddit.com/r/MedicalGore/s/N07NfRzsoq

Etiopathology

• Pathophysiology: Arterial blood at high pressure and flow enters the venous system, causing the vein to arterialize (dilate, thicken, and remodel). This allows repeated cannulation and sufficient flow for hemodialysis.

Types (by site of anastomosis):

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Preferred access order: distal (radiocephalic) → proximal (brachiocephalic/basilic) → grafts → catheters.

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• Radiocephalic AVF (Brescia–Cimino fistula): distal forearm (radial artery → cephalic vein). Most common and first choice.
• Brachiocephalic AVF: upper arm (brachial artery → cephalic vein).
• Brachio-basilic AVF: requires basilic vein transposition.
• Less common sites: femoral, saphenous, or transposed upper arm fistulae (used when forearm options exhausted).

![Autologous arteriovenous fistulae (AVF) are generally created in the wrist or in the forearm (see the figure). The Brescia–Cimino radiocephalic AVF, first used in 1966, is still the procedure of choice today for most patients; a radiocephalic fistula is formed in the wrist by fusing the cephalic vein and radial artery, with the location where they meet termed the anastomosis. In the forearm, the types of fistula formed are generally brachiocephalic (fistula formed from the brachial artery and cephalic vein) and brachiobasilic transposition (fistula formed from the basilic vein and the brachial artery).

Figure adapted from Allon, M. & Robbin, M. L. Increasing arteriovenous fistulas in hemodialysis patients: problems and solutions. Kidney Int. 62, 1109–1124 (2002) Lawson, J.H., Niklason, L.E. & Roy-Chaudhury, P. Challenges and novel therapies for vascular access in haemodialysis. Nat Rev Nephrol 16, 586–602 (2020). https://doi.org/10.1038/s41581-020-0333-2](attachment:7c6af9e7-432a-48f5-876e-b9d6b49d7097:image.png)

Autologous arteriovenous fistulae (AVF) are generally created in the wrist or in the forearm (see the figure). The Brescia–Cimino radiocephalic AVF, first used in 1966, is still the procedure of choice today for most patients; a radiocephalic fistula is formed in the wrist by fusing the cephalic vein and radial artery, with the location where they meet termed the anastomosis. In the forearm, the types of fistula formed are generally brachiocephalic (fistula formed from the brachial artery and cephalic vein) and brachiobasilic transposition (fistula formed from the basilic vein and the brachial artery).

Figure adapted from Allon, M. & Robbin, M. L. Increasing arteriovenous fistulas in hemodialysis patients: problems and solutions. Kidney Int. 62, 1109–1124 (2002) Lawson, J.H., Niklason, L.E. & Roy-Chaudhury, P. Challenges and novel therapies for vascular access in haemodialysis. Nat Rev Nephrol 16, 586–602 (2020). https://doi.org/10.1038/s41581-020-0333-2

Surgical technique:

![Forearm anatomy (A) resulting in torsional stress zone with end-to-side technique (B): The most common surgical technique for fistula formation is an end-to-side anastomosis formation, where the end of the vein is connected to the side of the donor artery (see the figure). In a side-to-side technique, the sides of the vein and artery are connected, and in the end-to-end technique, the ends of the vein and artery are connected. The formation of the anastomosis results in torsional stress, which is compounded by blood flow in the vessels and may affect fistula maturation. Novel surgical techniques and devices that manipulate the angles of the fistula may affect blood flow and stress on the vessels, subsequently affecting stenosis formation and fistula maturation.

Bharat, A., Jaenicke, M. & Shenoy, S. A novel technique of vascular anastomosis to prevent juxta-anastomotic stenosis following arteriovenous fistula creation. J. Vasc. Surg. 55, 274–280 (2012).](attachment:baefecbd-1259-4783-9cf8-21ff63c7a691:image.png)

Forearm anatomy (A) resulting in torsional stress zone with end-to-side technique (B): The most common surgical technique for fistula formation is an end-to-side anastomosis formation, where the end of the vein is connected to the side of the donor artery (see the figure). In a side-to-side technique, the sides of the vein and artery are connected, and in the end-to-end technique, the ends of the vein and artery are connected. The formation of the anastomosis results in torsional stress, which is compounded by blood flow in the vessels and may affect fistula maturation. Novel surgical techniques and devices that manipulate the angles of the fistula may affect blood flow and stress on the vessels, subsequently affecting stenosis formation and fistula maturation.

Bharat, A., Jaenicke, M. & Shenoy, S. A novel technique of vascular anastomosis to prevent juxta-anastomotic stenosis following arteriovenous fistula creation. J. Vasc. Surg. 55, 274–280 (2012).

Hemodynamics

• Direct arterial–venous connection → arterializes the vein (thickening and dilatation).