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Background: Accessory cephalic vein (ACV) ligation can circumvent immature arteriovenous fistula (AVF). However, no consensus has been reached on the definite timing of ACV ligation. This study aimed to retrospectively analyze the correlation between preoperative Doppler ultrasonography (DUS)-assessed specific ACV diameter-cephalic vein diameter ratio (r) and early dysfunction of Radial artery-Cephalic vein (RC)-AVF in order to improve the early maturity rate of RC-AVF., Methods: A total of 258 patients who underwent RC-AVF at The Third Affiliated Hospital, Sun Yat-sen University from 1 June 2018 to 31 March 2022 were included in this study. The inclusion criteria were as follows: (I) cephalic vein ≥2.0 mm and radial artery ≥1.5 mm, suitable for RC-AVF establishment; (II) presence of an ACV. As per the specific r determined using preoperative DUS assessment, all patients were classified into two groups: Group A (r<0.8) and Group B (r≥0.8). Furthermore, patients in each group were divided into intervention and non-intervention subgroups based on the presence or absence of intraoperative ACV ligation, respectively. Patient data including age, sex, underlying disease, AVF side, and radial diameter were compared. The difference of maturity rate between participants in the intervention group and non-intervention group with different r values was analyzed, so as to obtain the relationship between different r values and maturity rate., Results: No statistical differences were observed between the intervention and non-intervention subgroups in the two groups in terms of sex, age, comorbidities, complications, AVF side, radial artery, cephalic vein, and ACV diameters (P>0.05). When r<0.8, the maturity rates of the intervention group and the non-intervention group were 80% and 92.98%, respectively, χ 2 =4.561. The difference in maturation rate between the intervention and non-intervention subgroups was insignificant (P=0.075) when r<0.8. When r≥0.8, the maturity rates of the intervention group and the non-intervention group were 89.83% and 45.45%, respectively, χ 2 =25.943. The difference in maturation rates between the intervention and non-intervention subgroups was significant when r≥0.8 (P<0.001)., Conclusions: Preoperative DUS suggested a correlation between r≥0.8 and early immaturity of RC-AVF. Therefore, concurrent intraoperative ACV ligation should be carried out when preoperative r is ≥0.8, as it may reduce the early power dysfunction of RC-AVF., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://qims.amegroups.com/article/view/10.21037/qims-23-271/coif). The authors have no conflicts of interest to declare., (2023 Quantitative Imaging in Medicine and Surgery. All rights reserved.)