Chapter 1: Arteriovenous Fistulae (AVF)
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Healthcare management is inherently complex1. End Stage Renal Disease (ESRD) is no exception. Yet ESRD testing offers a unique opportunity for systematic study. Compared with other chronic diseases, it affects a smaller, confined patient population. Patients who receive dialysis are under frequent clinical observation, typically three sessions per week for hemodialysis sessions in specialized units. This regular contact enables unusually detailed monitoring and robust data collection23456.
The United States Renal Data System (USRDS) has capitalized on this, publishing comprehensive global reports on ESRD management and outcomes6. These data reveal striking variation between regions and countries in the selection and application of Renal Replacement Therapy (RRT), including transplantation6. To navigate such complexity, these and future chapters employ Structured Analytic Techniques (SATs), which use deliberate, systematic evaluation of the variables that influence clinical practice7.
Clinical intuition—often fast and efficient are shaped by your own opinions and local customs—can be valuable but also introduces bias. For example, the common practice of preserving the non-dominant arm for future fistula creation may protect an unsuitable limb, leaving the dominant arm with better vasculature underutilized. Evidence-based, structured approaches are required to avoid such pitfalls7. Our goal is to contrast intuition with analytic reasoning, highlighting how collaborative decision-making, validated data, and evidence-based tools that will improve ESRD planning and outcomes.
This publication is designed as a dynamic, living resource. Through extensive linking to figures, documents, videos, and references, readers can access guidelines, glossaries, data sources, and training materials in real time. The text is reviewed by an international group of contributors and will be periodically updated as new evidence emerges. There is no consistent protocol or technique for native vein surgery9. Recent percutaneous techniques for both AVF and peritoneal dialysis placement is being advanced1012 and have recently been labeled Minimal Invasive Dialysis Access or MIDA13 Recent UK hemodialysis guidelines14, CMS updates1516, and innovations in minimally invasive dialysis access13 are already included in this evolving framework. Other recent work in progress, in press or online will be updated in follow up reports in 2026171819202122. The Editor Ingemar Davidson, MD, PhD, FACS Dallas, Texas www.KidneyAcademy.com
Contributors to KidneyAcademy.com
NC Liew. MD. University Putra Malaysia, Serdang, Selangor, Malaysia
JJ Swinnen. Prince of Wales Hospital, Sydney, NSW, Australia
T Litchfield. President of Access Solutions. Milwaukee, WS
M Gallieni, MD Professor of Nephrology. Editor, the Journal of Vascular Access. Sacco University, Milan, Italy
N Inston, MD, PhD. Consultant Surgeon. University. Queen Elizabeth Hospital Birmingham, UK
M Ali Sheta, MD, FASN, FASDIN. Houston Kidney Specialists. Houston TX
G Beathard, MD. Clinical Professor, University of Texas Medical Branch Galveston, TX
D Slakey, MD, PhD. Belmont University Frist College of Medicine, Nashville, TN
Therese Wykoff, BS, MS, Founder Ren Consulting, Boulder, CO
U Hahn-Lundstrom, MD, PhD. Professor Int. Medicine, Karolinska Institute, Stockholm Sweden
U Hedin, MD, PhD. Professor of Surgery, Karolinska Institute, Stockholm Sweden
T Davis, General Glyphics, Inc. Dallas TX
S White, ScreenPlan Productions, Dallas TX
Abstract – Chapter 1: Arteriovenous Fistulae (AVF)
Arteriovenous fistulae (AVF) remain the preferred access for hemodialysis, yet their creation and long-term function are plagued by several patients, anatomical, surgical, and systemic factors. Document 1) or venous “real estate” lists a number of glossaries, or acronyms describing acronyms and vocabulary used in ESRD literature This chapter examines AVF through the lens of structured analysis, contrasting intuitive decision-making with evidence-based strategies 7. Key topics include:
- Criteria for patient and vessel selection
- Principles of atraumatic surgical technique
- The three principal AVF types and their indications
- Timeframes and predictors of AVF maturation
- The central role of ultrasound in vascular mapping (Document 2)
- Early AVF failure: causes, prevention, and treatment
- Late failure: mechanisms and management strategies
- Common complications and their resolution
- The implications of “secondary fistula” planning for long-term vascular access.
By integrating global data from the USRDS with practical surgical experience (6), this chapter underscores both the regional variability of practice patterns and the universal need for structured, evidence-driven approaches (Document 3).
Select References from Instructions of Chapter 1 on AVF
These references in chapter 1 have been selected in the attempt to be non-biased, an impossible task. To compensate, we have added an expanded list of 512 references covering all aspects of native vein AVF (Document 4). (Courtesy of Dr. G Beathard).
Pre study multiple choice test questions are linked (PRE TEST) MCQ) (Document 5) Also, at the end of this chapter the correct answers are listed in this MCQ document for self-test if reading this chapter improved your knowledge.
The access to this material is free. We ask you to register at the attached form for our internal data collection. We welcome your comments and suggestion in an effort to improve readers’ experience. You may do so by emailing me at drd@ingemardavidson.com.