What are the common arterial‑venous connection sites used to create hemodialysis fistulas?

Common Arteriovenous Connection Sites for Hemodialysis Fistulas

The KDOQI guidelines define four primary named fistula configurations based on their arterial-venous connection points: the Brescia-Cimino (radiocephalic) fistula at the wrist, the brachiocephalic fistula at the elbow, the Gracz fistula in the proximal forearm, and the snuff-box fistula in the hand. 1

Primary Named Fistula Configurations

Brescia-Cimino (Radiocephalic) Fistula

• Connection point: Radial artery to cephalic vein at the wrist 1
• This is the gold standard and first-choice access for hemodialysis 1, 2
• Preserves all proximal vessels for future access creation 2
• Requires minimum vessel diameters of 2.0 mm for the radial artery and 2.5 mm for the cephalic vein 1, 3

Brachiocephalic Fistula

• Connection point: Brachial artery to cephalic vein at the antecubital fossa (elbow region) 1, 2
• This is the recommended second-choice access when wrist vessels are inadequate 1, 2
• Provides higher blood flow than wrist fistulas but consumes more proximal vessels 2
• Recommended anastomosis diameter of 7-10 mm, though 5-6 mm may reduce steal syndrome risk 2

Gracz Fistula

• Connection point: Proximal radial artery to a perforating branch of the cephalic or median cubital vein below the elbow 1
• Valuable option when forearm veins are destroyed or distal radial arteries are calcified 4
• Can be created as a radial artery-perforating vein anastomosis with side-to-end or end-to-end technique 4

Snuff-Box Fistula

• Connection point: Branch of the radial artery to an adjacent vein in the anatomic snuff box of the hand 1
• Most distal option, preserving maximum future access sites 1
• Should be considered first in the ideal peripheral-to-central sequence 1

Additional Connection Configurations

Radio-Median Cubital Fistula at Elbow

• Connection point: Radial artery to median cubital vein at the elbow, approximately 4 cm below the elbow crease 5
• Alternative to brachiocephalic fistula that avoids vascular steal syndrome 5
• Leads to dilation of both cephalic and basilic veins 5

Ulno-Basilic Fistula

• Connection point: Ulnar artery to basilic vein 5
• Less commonly used configuration 5

Endovascular Fistula (EndoAVF)

• Connection point: Originally described as proximal ulnar artery to proximal ulnar vein anastomosis 1
• Created by endovascular techniques rather than open surgery 1
• Uses side-to-side anastomosis technique 6

Hierarchical Selection Algorithm

The KDOQI guidelines mandate a strict distal-to-proximal sequence to preserve maximum future access options: 1

1. First: Snuff-box fistula (hand) 1
2. Second: Brescia-Cimino radiocephalic fistula (wrist) 1, 2
3. Third: Forearm cephalic fistula at dorsal branch or mid-forearm 1
4. Fourth: Brachiocephalic fistula (elbow) 1, 2
5. Fifth: Transposed basilic vein fistula (upper arm) 1, 2
6. Last autogenous option: Exotic configurations (chest wall, internal jugular) 1

Arterial Inflow Options by Location

Potential arterial inflow sites include: 1

• Radial artery at the wrist 1
• Brachial artery in the antecubital fossa 1
• Brachial artery in the lower arm 1
• Brachial artery just below the axilla 1
• Axillary artery 1
• Femoral artery (avoid when possible) 1

Venous Outflow Options by Location

Potential venous outflow sites include: 1, 7

• Median antecubital vein (primary target for forearm loop grafts) 7
• Proximal and distal cephalic vein 1, 7
• Basilic vein at elbow level 1, 7
• Basilic vein at upper arm level 1, 7
• Axillary vein 1, 7
• Jugular vein 1
• Femoral vein (strongly discouraged due to central stenosis risk in transplant candidates) 1, 7

Critical Pitfalls to Avoid

Never create a proximal fistula as the first choice without exhausting distal options, as this eliminates future access sites for patients who may need dialysis for decades 1, 2

Always perform preoperative vascular mapping with duplex ultrasound to assess vessel adequacy before proceeding, as inadequate vessels lead to high failure rates 1, 2, 3

Avoid placing ipsilateral central venous catheters while a fistula is maturing, as this risks central venous stenosis that can compromise fistula function 2

Never use subclavian vein access for temporary catheters in patients who may need future upper extremity access, as subclavian stenosis is common and devastating 1, 2