The radiocephalic fistula dates back to the 1960s with good long-term survival and a low incidence of complications. The standard practice of creating an end cephalic vein to side radial artery fistula (ETS) has a high incidence of early thrombosis and failure to mature, which limits its efficacy. The hypothesis is that a 1.3- to 1.5-cm side-to-side with distal vein ligation anastomosis (STS) is associated with a lower early thrombosis rate and higher primary patency rate. We retrospectively evaluated all radiocephalic fistulas created at our hospital from January 1, 2012, to December 31, 2012, comparing a 1.3- to 1.5-cm STS anastomosis to the ETS anastomosis. Primary endpoints were patency at three and six months and the secondary outcome was suitability for cannulation. An ETS anastomosis resulted in an early thrombosis rate, 3-month cannulation rate, and 6-month primary patency rate of 14, 30, and 48 per cent, respectively. Outcomes from the STS technique were significantly improved with no early thrombosis (P < 0.05), 3-month cannulation rate of 67 per cent (P < 0.03), and a primary patency of 75 per cent (P = 0.03). A STS radiocephalic fistula with distal vein ligation is superior to the ETS radiocephalic fistula. Early thrombosis, 6-month primary patency, and cannulation rates were significantly improved.