A surgeon creates an AV fistula by connecting an artery directly to a vein, frequently in the forearm. Connecting the artery to the vein causes more blood to flow into the vein. As a result, the vein grows larger and stronger, making repeated needle insertions for hemodialysis treatments easier.  

If veins are too small to develop fistula, then a vascular access that connects an artery to a vein using a synthetic tube, or graft, implanted under the skin will be chosen. The graft becomes an artificial vein that can be used repeatedly for needle placement and blood access during hemodialysis. 

The other option is a venous catheter as a temporary access. A catheter is a tube inserted into a vein in the neck, chest, or leg near the groin. It has two chambers to allow a two-way flow of blood. Once a catheter is placed, needle insertion is not necessary. Left arm is chosen for arteriovenous fistula for right-handed patients, usually a local anesthetic is given so that the risk is reduced greatly and the whole procedure completes within one and half hours. Analgesic and antibiotics are given to postoperative in order to reduce the pain and infection.