Free flap reconstruction of a defect on an extremity with an arteriovenous fistula is a surgical challenge due to the unique hemodynamic characteristics of an arteriovenous fistula and its potential complications. There is a paucity of evidence in the literature describing free flap reconstructions adjacent to arteriovenous fistulae. We present a successful case of an 86-year-old man with end-stage renal disease who underwent an anterolateral thigh free flap reconstruction of a hand defect immediately adjacent to his pre-existing radiocephalic fistula. The free flap recipient vessels used were the dorsal branch of the ulnar artery, a tributary of the basilic vein and a vena comitans. Recipient veins were carefully chosen based on intra-operative barometry. The free flap reconstruction showed no signs of venous insufficiency or compromise at any stage. The radiocephalic fistula was never disrupted, nor was there any complication regarding the arteriovenous fistula. The patient maintained his regular hemodialysis throughout his care with routine arteriovenous fistula access. The patient was reviewed six months post-op with no complications and he had returned to living independently in his own home. From our experience of this case, pre-existing arteriovenous fistulae should not preclude patients from undergoing free flap reconstructions if indicated.