Hemodialysis first became available, albeit in a limited fashion, in 1962 in Seattle. The first hemodialysis fistula was created in 1966. Until the 1980s, relatively low median dialysis flow rates were used, and thus even patients with small-veined fistulas could achieve adequate hemodialysis. By the mid-1980s, it was established that urea clearance time could be improved with higher blood flows during dialysis, with very little increase in dialysis time. This, in turn, led to a preference for grafts over fistulas that could more easily handle the increase in flow required and could be used sooner after surgery than fistulas.

In 1997, the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (KDOQI) published a set of evidence-based practice guidelines for vascular access. These guidelines recommended that the primary placement for hemodialysis be autogenous arteriovenous fistula in preference to synthetic grafts. Although arteriovenous fistulas have a higher primary failure rate than arteriovenous grafts, the fistulas are less prone to infection and thrombosis and require less corrective intervention.

There are many different configurations of arteriovenous fistulas. The preferred and most commonly used are created in the upper extremity: radiocephalic, brachiocephalic, and brachiobasilic transposition ( Fig. 4-1 ). Brachiobasilic transposition has been increasingly used in patients possessing veins of insufficient caliber to support the preferred radiocephalic or brachiocephalic fistulas. This involved the transposition of the basilic vein, a vein not used for venipuncture, and therefore much less likely to be diseased than the cephalic vein, to a more superficial level, by dissecting and tunneling the vein to a position that can be more easily reached by the dialysis needle (1 to 1.5 inches in length). The normal volumetric flow through an arteriovenous fistula is held to be >600 mL/min.

Common types of arteriovenous fistulas. Left, Radiocephalic fistula. Middle, Brachiocephalic fistula. Right, Brachiobasilic transposition.

(Redrawn from Allon M, Robbin ML. Increasing arteriovenous fistulas in hemodialysis patients: problems and solutions. Kidney Int. 2002;62:1109-1124; figures 5 to 7; used with permission.)

Between 20% and 50% of fistulas fail to mature, due principally to the development of stenosis at the venous anastomosis, but also to a lesser extent, due to the presence of large branch veins.