Why is an arteriovenous graft placed in one arm while an arteriovenous fistula is placed in the other arm?

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Last updated: March 21, 2026 • View editorial policy

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Why Grafts and Fistulas Are Placed in Different Arms

Placing an arteriovenous graft in one arm while preserving the other arm for a fistula follows a distal-to-proximal, sequential vascular access strategy that maximizes the total number of future access sites available over a patient's dialysis lifetime.

Strategic Vessel Preservation

The fundamental principle is to preserve vessels for future vascular access needs, particularly for patients expected to have prolonged durations on hemodialysis 1. This approach recognizes that:

  • Each access site is a finite resource - Once an upper arm access is created, it eliminates future options in that limb 1
  • Bilateral upper arm accesses should be avoided in younger individuals with long expected survival on dialysis, as this eliminates all future access options 1
  • The distal-to-proximal approach (starting with forearm sites before moving to upper arm) provides the best opportunity to preserve vessels for future vascular access sites 1

The Sequential Access Algorithm

The KDOQI guidelines recommend the following hierarchy 1:

  1. First choice: Distal forearm radiocephalic fistula (snuffbox or distal radiocephalic)
  2. Second choice: Proximal radiocephalic or brachiocephalic fistula
  3. Third choice: Upper arm fistula (brachiobasilic transposition) or forearm graft
  4. Last resort: Upper arm graft

Why Separate Arms Matter

Preserving one arm entirely allows for a complete sequential plan in that limb 1. For example:

  • If you place a forearm graft in the right arm, you preserve the entire left arm for a distal fistula → proximal fistula → upper arm fistula sequence
  • This strategy can provide 4-5 total access sites over a patient's lifetime rather than 2-3 if both arms are used simultaneously 1

The Unintended Consequence of "Fistula-First"

An important caveat: The enthusiasm for achieving "fistula targets" has led to an increasing number of upper arm fistulas being created as first accesses in the United States, which inadvertently and negatively affects patients' future vascular access options 1. This practice should be avoided.

Forearm Grafts Can Create Future Options

Interestingly, forearm loop grafts may actually preserve and potentially create new upper arm access sites 2. In patients with inadequate upper arm veins at the time of forearm graft placement, approximately 36% became candidates for upper arm fistulas after the forearm graft failed, as the increased flow through the graft dilated previously inadequate upper arm veins to ≥3 mm 2.

Comparable Patency Between Locations

When choosing between forearm and upper arm grafts specifically, patency rates are comparable 3. The forearm location should still be considered first to preserve the maximum number of access sites 3, but this is about preservation strategy rather than superior outcomes.

Clinical Decision Framework

For patients with long expected dialysis duration:

  • Start with the most distal site possible in one arm
  • Preserve the contralateral arm completely for future use
  • Move proximally within the same arm as each access fails
  • Only use the contralateral arm when all ipsilateral options are exhausted 1

For patients with limited life expectancy or near-term transplant:

  • The preservation strategy is less critical
  • Focus on creating the most reliable access for their expected time on dialysis 1

References

1
Guideline

kdoqi clinical practice guideline for vascular access: 2019 update.

American Journal of Kidney Diseases, 2020

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.