Which anatomical site is most appropriate?

Optimal Anatomical Site Selection for Vascular Access

The most distal site possible should always be considered first for vascular access placement to preserve proximal sites for future access needs. 1

Preferred Order for Arteriovenous Fistula (AVF) Placement

The optimal sequence for AVF creation follows a distal-to-proximal approach:

1. First choice: Wrist (radiocephalic) fistula

   • Located at the "snuff box" at the base of the thumb or standard Brescia-Cimino wrist position
   • Advantages:
     • Simple to create
     • Preserves proximal vessels for future access
     • Low complication rates (minimal vascular steal, low thrombosis and infection rates) 1
   • Only major disadvantage: Lower blood flow rates compared to other fistula types

2. Second choice: Forearm options

   • Forearm cephalic fistula at dorsal branch
   • Mid-forearm cephalic fistula

3. Third choice: Elbow (brachiocephalic) fistula

   • Advantages:
     • Higher blood flow compared to wrist fistula
     • Cephalic vein in upper arm is easy to cannulate 1
   • Disadvantages:
     • Slightly more difficult to create surgically
     • May result in more arm swelling

4. Fourth choice: Transposed basilic fistula

Arteriovenous Graft (AVG) Placement (if fistula not feasible)

If AVF creation is not possible, the preferred order for AVG placement is:

1. Forearm loop
2. Upper-arm (straight or curved)
3. Upper-arm loop
4. Thigh (only after exhausting upper-extremity options)

Rationale for Distal-to-Proximal Approach

Starting distally and moving proximally is critical because:

1. It preserves the maximum number of potential sites for future access creation
2. Vascular access often fails over time, requiring multiple access sites throughout a patient's lifetime
3. Prematurely bypassing distal sites is considered a "tragedy" that limits future options 1

Important Considerations

• Mortality impact: Fistulae are associated with increased survival compared to grafts (RR 1.47) and catheters (RR 2.3) 1
• Infection risk: Fistulae have lower infection rates than grafts, which have lower rates than catheters 1
• Maturation time: Allow at least 4 months for wrist fistula maturation before considering alternative access 1
• Thigh placement caution: Thigh placement should be considered a last resort due to significantly higher infection risk 1

Special Circumstances

• If imaging studies demonstrate inadequate vessels for distal placement, proximal sites may be justified
• Patients at high risk for arterial "steal" syndrome may require more proximal placement 1
• For patients with kidney transplant potential, avoid femoral catheter access 1

The systematic approach of preserving distal access sites first is essential for long-term dialysis access planning and directly impacts patient morbidity, mortality, and quality of life through reduced complications and improved vascular access longevity.