During a seven year period, 189 expanded polytetrafluoroethylene (PTFE) grafts for vascular access were implanted in 131 patients with end stage renal disease requiring long term hemodialysis. Over-all cumulative patency rate for all grafts was 76 per cent at 12 months, 50 per cent at 36 months and 40 per cent at 60 months. Forearm grafts of loop configuration yielded greater over-all patency rates and required fewer revisions than forearm grafts of straight configuration. Graft thrombosis was the universal indicator of graft malfunction. In the instance of a malfunction, immediate thrombectomy followed by angiography was considered essential to decisions regarding further therapy. Of 95 grafts that malfunctioned, 49 ultimately required revision, extending the survival to a rate equaling that of continuously functioning grafts. Extensive venous stenosis limiting outflow and multiple intragraft stenosis were the main causes of graft failure. For patients in whom all vessels of the upper extremity had been exhausted, thigh grafts of the loop configuration and axilloaxillary grafts proved to be satisfactory alternatives. Although PTFE grafts are not the final solution for vascular access in hemodialysis, in many instances, they will serve well, provided the surgeon gives proper consideration to their most efficacious use.