Fistula First, now a CMS "Breakthrough Initiative", sets the eventual goal of 66% prevalence of arteriovenous (AV) fistulas in the U.S. dialysis population. The benefit of an AVfistula as the hemodialysis access has been clearly demonstrated; yet the current incidence of AV fistulas in patients new to dialysis in the U.S. is extremely low and prevalence rates are approximately half the eventual target rate. In this article, the components of an Integrated Vascular Access Program are described. One of these is a dedicated Vascular Access Center (VAC), a facility specializing in radiographic and interventional procedures for the vascular access care of patients with ESRD. Procedures carried out in a dedicated VAC are described and are shown to support both K/DOQI and the Fistula First "Change Package" in terms of promoting increased prevalence of AV fistulas. These include preoperative vessel mapping, fistula maturation, fistula maintenance, and identification of candidates for secondary fistula. The above type procedures that were carried out in our dedicated VAC in 2004 are described. These included vessel mapping (n=220), fistula maturation procedures (n=104), and fistula maintenance procedures (n=103). The results suggest that the shift to a "fistula culture" within a dialysis practice requires a significant number of interventional procedures--both maturation and maintenance types. A dedicated VAC can efficiently carry out these procedures and is an important component of an Integrated Vascular Access Program.