Maintenance and complications of vascular access (VA) for hemodialysis (HD) represent the leading cause of morbidity and health care cost among end stage renal disease population. To define the reasons for the use of a particular VA at the beginning of replacement treatment, we prospectively evaluated the early failure rate and survival of arterovenous fistula (AVF) in 183 patients. These patients had high prevalence of cardiovascular risk factors and co-morbid conditions, and began HD in our renal unit from the 1st of January 1995. As a part of this study the present analysis focuses on potential predictors of early failure of the first AVF (within the first 7 days after the operation). Overall, 279 AVF were prepared: 193 at the wrist and 86 at the upper arm, including 11 prosthetic grafts; 150 patients (82%) were given a distal AVF in the first operation. Our conservative policy resulted in a relatively high prevalence of native AVF in use among our prevalent HD patients (84.3%). Early failure of the first VA was 10.4%. Multivariate analysis showed that this event was neither significantly associated with all traditional risk factors and co-morbids tested, nor with the operating surgeon. We conclude that in this prospectively studied cohort, the high rate of native AVF created in order to preserve the vascular bed, though associated with a high early failure rate unaffected by traditional cardiovascular risk factors, resulted in a low proportion of permanent catheters and arterovenous grafts in use among prevalent HD patients. (The Journal of Vascular Access 2001; 2: 154-160).