Background: The subsequent development of vascular access techniques and devices now permits patients to be maintained on dialysis for decades. Aim of study: To evaluate the most possible causes behind repeated arteriovenous (AV) access failure in ESRD patients and finding the relationship between those causes and the timing of access failure, and putting the possible solutions in the form of interventions and guidelines for those patients. Patients and methods: This retrospective non-randomized study was conducted in department of vascular surgery, Al-Azhar University Hospitals – Cairo (Al-Hussein and Sayed Glal Hospitals). This study was conducted on 100 ESRD patients on regular hemodialysis and with repeated AV access failure; at least two failed accesses for each patient. The total number of failed accesses was 245 where 230 accesses were autogenous AV fistulae and 15 were synthetic bridge grafts in upper limb. Results: Among the cases of access thrombosis 25.5% were associated with access stenosis, 10.5% with hypotension, and 2.5% with external compression. Among the cases of failure of maturation 16% were due to small vein diameter (less than 2.5 mm), 9% associated with hypotension, and 7% with hypotension together with central venous stenosis.