Aortic arch calcification (AAC) is recognized as an important cardiovascular risk factor in patients with end-stage renal disease (ESRD). The aim of the study was to evaluate the impact of AAC grade on patency rates of arteriovenous fistula (AVF) in this specific population. The data of 286 ESRD patients who had an initial AVF placed were reviewed. The extent of AAC identified on chest radiography was divided into four grades (0-3). The association between AAC grade, other clinical factors, and primary patency of AVF was then analyzed by Cox proportional hazard analysis. The multivariate analysis demonstrated that the presence of AAC grade 2 (hazard ratio (95% confidence interval): 1.80 (1.15-2.84); p = 0.011) and grade 3 (3.03 (1.88-4.91); p < 0.001), and higher level of intact-parathyroid hormone (p = 0.047) were associated with primary patency loss of AVF. In subgroup analysis, which included AVF created by a surgeon assisted with preoperative vascular mapping, only AAC grade 3 (2.41 (1.45-4.00); p = 0.001), and higher intact-parathyroid hormone (p = 0.025) level were correlated with AVF patency loss. In conclusion, higher AAC grade and intact-parathyroid hormone level predicted primary patency loss of AVF in an ESRD population.