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Nicola Pirozzi,1 Nicoletta Mancianti,2 Jacopo Scrivano,1 Loredana Fazzari,1 Roberto Pirozzi,1 Matteo Tozzi3 1Interventional Nephrology Unit, Nephrology and Dialysis Department, CdC Nuova ITOR, Roma, Italy; 2Nephrology, Dialysis and Transplant Unit, University Hospital of Siena, Siena, Italy; 3Vascular Surgery, University of Insubria – Asst Settelaghi Varese, Varese, ItalyCorrespondence: Nicola PirozziInterventional Nephrology Unit, Nephrology and Dialysis Department, CdC Nuova ITOR, Via di Pietralata 162, Rome, 00158, ItalyEmail nicola.pirozzi1@gmail.comAbstract: Autogenous radial–cephalic direct wrist arteriovenous fistula (RC-AVF) in the non-dominant arm is the gold standard for dialysis vascular access. However, the RC-AVF non-maturation rate is significant (≃ 40%) due to an increasingly elderly and comorbid population incidence. A detailed identification of the biological cascade underlying arteriovenous fistula (AVF) maturation could be the key to clinical research aimed at identify the group of patients at risk of primary AVF failure. Currently, careful post-operative monitoring remains the most crucial aspect to overcome the problem of impaired maturation. Up to 80% of patients with immature RC-AVF have problems potentially solvable with early endovascular or surgical correction. Physical examination by experienced practitioners in conjunction with duplex ultrasound examination (DUS) can identify physical signs of non-maturation, understand the underlying cause, and drive for a tailored early planning to treat the complication. New approaches for the early assessment of AVF maturation are under study. Techniques to promote RC-AVF maturation performed through the administration of pre-or peri-operative drugs have missed up to now to prove an efficacy in improving fistula success. The new techniques tested after surgery appear to hold future promise for improving fistula maturation.Keywords: arteriovenous fistula maturation, hemodialysis, early failure, rule of six, vascular access