There is a continued need for improved strategies to create and to maintain autogenous arteriovenous fistulas (AVFs). The autogenous radial-cephalic AVF is the widely recognized first choice, and brachial-cephalic AVFs are often the second choice. There is variable superficial venous anatomy nearing the antecubital fossa. The median antebrachial vein has dual outflow to both the cephalic and basilic veins. An AVF using the median antebrachial vein (MAV-AVF) is a less commonly performed procedure that affords unique benefits. Between August 2016 and December 2018, there were 14 autogenous MAV-AVFs created at our institution. The proximal radial artery was used as inflow for 12 of these AVFs, and the brachial artery was used for the remaining 2. During the study period, 14 patients underwent AVF creation. One patient experienced a postoperative deatah unrelated to surgery. Of the remaining 13 patients who underwent MAV-AVF creation, 30-day patency was 100%. One patient sustained thrombosis of the fistula 27 months after the index operation, and five patients required subsequent reoperations. Two patients were able to access the fistula using one needle in the cephalic vein and a second needle in the basilic vein immediately after fistula maturation. These patients later underwent basilic vein superficialization because stenosis of the cephalic vein precluded access 12 and 18 months after the index operation. One patient required ligation of the basilic vein for failure of fistula maturation due to competing outflow veins. Two patients underwent ligation of the basilic vein to treat ischemic steal syndrome. All five of these patients were able to continue to access the AVF after reoperation. This series demonstrates that an autogenous AVF using median antebrachial vein as outflow is a viable option for permanent hemodialysis access. The dual outflow of the MAV-AVF has unique benefits and challenges. Both the cephalic and basilic veins can be used for hemodialysis access. If the basilic vein is the dominant outflow, superficialization may be required. Patients with MAV-AVFs can also have complications of high-outflow fistulas, which are easily treated with ligation of one of the outflow veins while maintaining viability of the AVF. Ligation of competing outflow veins is occasionally required to promote fistula maturation. The MAV-AVF is a valuable tool in the vascular surgeon’s armamentarium, with the unique outflow anatomy allowing multiple possible revisions to prolong its life before requiring progression to a more proximal fistula or synthetic graft.