End stage renal disease is common in the United States. It is most commonly caused by diabetes and hypertension. Renal function progressively declines over an unpredictable period of months to years, such that the kidneys are no longer able to perform their function. If failing renal function is not corrected or aided, premature demise is certain. Fortunately, several reliable techniques exist for establishing durable vascular access to aid in renal replacement therapy, specifically hemodialysis. Here we present the case of a middle aged male with progressive renal failure who underwent arteriovenous fistula creation for the purposes of aiding in renal replacement. We outline the scope of the problem, its natural history, preoperative care, selected intraoperative techniques, and relevant postoperative considerations for this process.