Background: Failure or delayed maturation of arteriovenous fistula (AVF) in patients with end-stage renal disease (ESRD) who require hemodialysis (HD) can lead to catheter-related complications as bacteremia and sepsis with the resultant high morbidity and mortality. Small- diameter veins are often a limiting factor for the successful creation of arteriovenous fistulas (AVFs). Balloon-assisted maturation (BAM) is a recent, innovative, yet controversial method for developing autogenous arterio-venous fistulae (AVF).   Purpose: Is to evaluate the use of intraoperative primary balloon angioplasty (PBA) as a technique to upgrade the small-caliber or diameter veins during AVF construction in conjunction with sequential balloon- assisted maturation to salvage failing fistulas, expedited maturation & improve the patency of AVFs.   Materials and methods: Prospectively collected data over a 2-year period. Between January 2016 and December 2017, 121 patients who underwent AVF creation in two tertiary referral hospitals in Saudi Arabia, Vascular surgery Department, Nile Insurance Hospital & Vascular Surgery Unit, Benha University/Department of Surgery, Egypt, were retrospectively analyzed. The duration to maturation of the AVF was determined by comparing the period between the time of creation of the fistula and the first successful cannulation of the fistula for patients with ESRD on hemodialysis. Patients with peritoneal dialysis were excluded. Patients who underwent BAM or construction of AVF at an outside institution were excluded. Follow-up consisted reviewing of postoperative AVF duplex for patency, hemodialysis units, vascular and nephrology clinics databases, and telephone interviews. Successful outcome was determined as the functional ability to use the fistula for hemodialysis without surgical revision.   Results: Of the 136 PBA procedures, 119 (87.5%) remained patent and subsequently underwent BAM with a resulting functional AVF. These consisted of 106 of the original AVFs and 13 new AVFs created at other sites. Occlusions occurred in 30 of the 121 fistulas (24.8%), and 15 were salvaged using BAM techniques. The mean balloon diameter for all dilatations was 3.5 mm. Of the initial 121 AVFs placed, 106 (87.6%) were made functional and 30 failed due to occlusion. Fifteen were salvaged using recanalization techniques and sequential BAM. Of the remaining fifteen patients, 11 were unsalvaged and received AVFs at another site using PBA and BAM techniques and 4 required graft placement. One AVF had to be ligated secondary to steal syndrome with insertion of chronic hemodialysis catheter as an alternative access. Overall 116 patients (95.9%) received working AVFs. All fistulas were functioning at 90 days after the final BAM. Graft placement was necessary in only 4 of the 121 patients (3.3%).   Conclusion: The combination between PBA and BAM is an overall approach that facilitates AVF maturation, improves function, prolongs patency, and facilitates use of small-caliber veins as an autogenous vascular access. The shorter maturation times have reduced the overall need for indwelling catheters with their associated risks. The resulting large-diameter AVFs are easy to cannulate and are associated with improved flow and patency rates. Successful AVFs have been created using veins that would have otherwise been deemed unusable. Adoption of this conjoint technique should help meet the stringent demands for autogenous access placement defined by KDOQI and Fistula First Breakthrough Initiative (FFBI) and, thereby, improve the duration and quality of life for the hemodialysis patients