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Native arteriovenous fistulae (AVF) are the best options for chronic hemodialysis (HD) access. In elderly, diabetics or patients with late initiation of HD we need to adapt surgical procedures, taking advantage of any opportunity to overcame shortcomings and create a native dialysis access. The case that we present has the particularity of a deep cephalic vein that required superficialization of the acquired brachiocephalic AVF in a normal weight patient (body mass index = 18.6 kg/m2). At the intervention for fistula formation, the poor nutritional status (moderate malnutrition - albuminemia = 2.9 g/dL) and the thin walls of the vein obliged us to perform the two-step procedure: first the creation, then the transposition of the fistula. The presence of two collateral veins imposed a classical intervention that allowed the ligature of these tributary vessels for a better fistula maturation. There were no injuries of the vessels or inflammatory / infectious complications, no impediment for cannulation due to overlapping scar after superficialization. In the dialysis vascular access planning algorithm we must consider all the conditions of the patient, anatomical particularities and the best way to ensure the longevity of the AVF. All the techniques available must be considered as options. [ABSTRACT FROM AUTHOR]