Introduction : A well-functioning vascular access for hemodialysis plays a key role in the quality of life and clinical outcome of dialysis patients. Arterio-venous fistulae survive longer than grafts and catheters. However, their short term outcomes may not be as good.Patients & methods: This study was party retrospective and partly prospective. 235 patients were included in the study and the data for each case was recorded regarding the time of failure, the anatomical site responsible for such failure and also the cause of that failure. The management and the outcome of each case were recorded and the overall data were analyzed.Results: The commonest factors behind the intra-operative failure due to inflow problem were hypotension (18 patients) and anastomotic constriction by un-dissected bands of tissues or crossing vessel at the heel of the anastomosis (12 patients) ,while outflow problems was encountered much more frequent than the inflow problems mainly due to constricting agent over the proximal vein (52 cases). 49 fistulae were nonfunctioning immediately post-operative and failed within the 1st 24 hours post-operatively mainly due to hypotension (34 cases) in radio-cephalic ones. Early post operative failure (from day 2 up to 3 months) was encountered in 67 cases. Although hypotension is still the main cause of failure, yet, duplex scan remains as the cornerstone to map the sites and types of lesions responsible for such failure. The results of balloon angioplasty were promising with success rate of 90% for the stenotic lesions and 72.7% forthe recently occluded segments.Conclusion: Prophylaxis against failure starts by identifying the causes of failure and combating them. Making an algorithm is helpful for management of early AVF failure