The long-term survival of patients on hemodialysis is often limited by the exhaustion of vascular access sites. A fundamental principle of vascular access surgery is that the arteriovenous (AV) access be placed as far distally in the arm as possible. This principle enhances the secondary patency of the AV grafts by preserving the proximal veins for AV graft revision and provides venous outflow for a new AV access to be placed more proximally in the extremity. The standard straight and looped AV graft configurations violate this principle by bypassing long segments of vein in the extremity that could be used for AV graft revision or new AV graft placement. We have developed a novel AV graft configuration that preserves venous outflow and enhances the longevity of each AV access site. The purpose of this review is to describe the reverse J AV graft technique and to report our outcomes with the procedure. Between February 2004 and April 2007, 26 AV grafts were placed using the reverse J configuration. Eighteen (69%) AV grafts were placed in the upper arm, 7 (27%) were placed in the forearm, and 1 (4%) was placed in the thigh. Median follow-up was 320 days. The secondary AV graft patency was 90 per cent at 6 months, 84 per cent at 12 months, and 84 per cent at 18 months. Five AV grafts were subsequently revised to a loop configuration. Overall patient survival was 85 per cent at 6 months, 68 per cent at 12 months, and 62 per cent at 18 months. Compared with the standard straight and looped AV graft configurations, the reverse J AV graft configuration preserves the length of venous outflow in the extremity for AV graft revision or new AV graft placement. Therefore, the reverse J configuration enhances the secondary patency of AV graft patency and AV access site longevity.