From 1981 to 1986 a total of 499 operations were performed for permanent hemodialysis vascular access in 230 patients. At least 1 year's follow-up was achieved in all cases. This series is divided into 326 primary procedures and 173 secondary procedures. Of the primary procedures, there were 160 autogenous fistulas and 166 expanded polytetrafluoroethylene (PTFE) fistulas. The 156 secondary procedures consisted of 124 thrombectomies, 20 repairs of pseudoaneurysm, 12 fistula ligations, and 17 fistula excisions. The infectious complication rate (29/482) was 6%. Mean length of patency was 3.1 years for autogenous wrist fistula, 2.6 years for elbow fistula, 1.9 years for forearm loop PTFE, 2.1 years for straight forearm PTFE, 1.6 years for femoral popliteal PTFE, and 1.4 years for femoral arteriovenous loop PTFE. A vascular steal syndrome occurred in 8% of patients with autogenous elbow fistulas (4/48), compared with 1.7% (2/112) of patients with wrist fistulas and 1.8% (3/166) of those with PTFE fistulas. All infected fistulas required excision, and all fistulas associated with the steal syndrome required ligation. Use of PTFE to construct permanent hemodialysis vascular access has a significantly higher incidence of thrombosis, infection, pseudoaneurysm formation, and limb loss (p less than 0.01 for all complications) and a significantly lower mean length of patency (p less than 0.0001) when compared with autogenous fistulas. Age, sex, hypertension, diabetes mellitus, and the use of perioperative antibiotics were not found to be related significantly to access complications.