The authors present the access results obtained with all 206 end-stage renal failure (ESRF) patients who began chronic hemodialysis in their clinic during the period of January, 1989, through January, 1994. In all patients they established initial vascular access in the distal forearm by anastomosis of the radial artery to the cephalic vein. The average age of the patients was forty-seven years; 61.2% were men and 38.8% women. Of these 206 patients, 154 (74.8%) developed no early complications, while 52 (25.2%) did. These latter developed 95 early complications, consisting of 91 instances of throm bosis (95.8%), 3 instances of bleeding (3.2%), and 1 instance of graft infection (1%). Of these 52 patients, 50 thrombosed their arteriovenous fistulas (AVFs), several recurrently. In 35 of these 50 patients, the authors reestablished a functioning direct AVF in the forearm at the same site, in 19 by thrombectomy and in 16 by thrombectomy plus redo of the anastomosis. By this aggressive policy of early reoperation for fistula complica tions, the authors were able to maintain a functioning direct AVF in the distal forearm in 191 (92.7%) of the patients. In 41 of these 206 patients, 80 late complications occurred, consisting of thrombosis, 74 (93%); bleeding, 2 (2.5%); graft thrombosis, 2 (2.5%); false aneurysm, 1 (1.2%); and infection, 1 (1.2%). The five-year primary and secondary patencies of the 156 direct AVFs that did not develop early thrombotic complications were 83% and 90% respectively, while those of the 35 direct AVFs that thrombosed early were 55% and 61%. The cumulative five-year patency rate for all patients' AVFs were 59% and 83% respectively. The primary and secondary patencies at three years of the 8 interposition graft AVFs were 44% and 63%.