The elderly constitute the main patient population of end stage renal disease (ESRD), and most of them had diabetes, hypertension and other complications. The main treatment for ESRD has been renal transplantation and hemodialysis. Because of scare kidney source, hemodialysis dominates the treatment at present. The guidelines for vascular pathways both at home and abroad set arteriovenous fistula (AVF) as the primary choice for patients undergoing maintenance hemodialysis. AVF enjoys advantages of long service life and fewer complications, but its establishment is difficult in the elderly patients due to vascular calcification, intimal hyperplasia and peripheral vascular diseases. The established AVF often has dysfunction, which requires intervention and remedy. Because the blood supply system in the forearm is valuable, most experts recommend that the principle of establishing AVF be in the sequence of the distal end of the arm and the posterior proximal end to the heart. This paper proposes that the establishing vascular pathway in the proximal forearm should be prioritized in the elderly patients with poor quality of blood vessels with advantages over the AVF at the distal end to the heart in terms of earlier maturation, higher success rate of first puncture and higher 2-year potency rate of of internal fistula. This provides a new idea for vascular surgeons to establish vascular pathway in the elderly patients with end-stage nephropathy.