The optimum access is a primary arterial venous fistula (AVF) using the patient’s own tissue if they have adequate vein. Vascular surgeons always prefer to start as far peripherally as possible and prefer to use the non-dominant arm if the vein there is suitable. Vascular surgeons follow these guidelines in creating AV fistulas:

• Always use natural vein before going to synthetic grafts.
• Try to use the patient’s non-dominant arm if the vein is suitable, so as to free up the dominant arm during the time on the dialysis machine.
• Start as peripherally as the vein allows, to increase options for the future if needed.
• Upper extremity fistulas are always preferable to lower extremity fistulas.
• The risks of creating an AVF or inserting a graft include bleeding, infection, clotting off of the fistula or graft with need for revision or re-operation, steal syndrome where too much blood goes out of the arm up the fistula and not enough is left in the hand. In some circumstances this could require tying off the fistula. After creation, fistulas need to “mature” (or grow in size) for a minimum of six weeks before use.