A thorough consideration of all factors contributing to successful dialysis access creation is necessary to achieve optimal outcomes. A high bifurcation of the brachial artery (brachioradial variant) occurs in greater than 20% of patients. Dialysis access was created in 22 limbs with this variant—15 fistula, and 7 prosthetic grafts. Nonmaturation occurred in 33% of fistula. Early thromboses occurred in 29% of prosthetic bridge grafts. In this experience, the brachioradial variant is associated with a relatively higher rate of fistula nonmaturation and prosthetic graft thromboses. These findings reinforce the critical role of preoperative imaging studies in dialysis access creation. A sound algorithm for the surgical management of the brachioradial variation facilitates decision making and will improve dialysis access outcomes.