arterio-venous fistulas. Compared with surgery, percutaneous trans-luminal angioplasty (PTA) has several advantages, including simplicity, minimal invasiveness, shorter time and less stress to the patients. It also enables immediate dialysis without the need for central venous catheter, reduces the risk of infection, and saves the patient's veins.6  PTA can be done angiographic or duplex guided. The rationale for duplex guidance is the avoidance of both radiation exposure and contrast reactions. Aim of the study: The aim of this study is to elaborate and evaluate the technique of duplex guided balloon angioplasty for failing AVF in Kasr Elaini Hospitals and to compare it with the angiographic guidance. Patients & methods: This study included 68 patients with failing hemodialysis AVFs (38 males and 30 females). After having informed written consent, every patient was subjected to history taking, physical examination and duplex evaluation. The patients were randomly allocated between two groups of management to have 34 patients in each group. These groups are the duplex guided group (A) and the angiographic guided group (B). The merits and limitations for duplex and angiographic guidance were compared. Results: Duplex guidance obviates the need for contrast injection, radiation exposure and angio-suite. It is a real time and gives an idea about the hemodynamics and is of less cost when compared with angiographic guidance. On the other hand, angiographic guidance is panoramic with better central veins delineation and with significantly shorter duration (ranged from 25 to 50 min with a mean of 36 min± 12). The duplex guided balloon angioplasty duration ranged from 35 to 110 min (mean 45 min ±18) (P value <0.05). Conclusion: Balloon angioplasty for failing AVF is an excellent promising modality for fistula salvage whether done under angiographic or duplex guidance with merits for each.