BACKGROUND Failure of vascular access leading to inefficient hemodialysis is the most common cause of morbidity in uremic patients. Careful observation of clinical signs and hemodynamic monitoring are vitally important to prevent complete fistula thrombosis. This study was undertaken to evaluate approaches for early detection and the application of percutaneous transluminal angioplasty in the treatment of failing vascular access. METHODS From August 1994 to August 1995, 32 uremic patients with failing vascular access (26 native arteriovenous fistulas, 6 polytetrafluroethlene (PTFE) grafts), presented signs of poor arterial flow, high venous pressure, significant recirculation, acute fistula thrombosis and persistent swelling of the access arm. These patients underwent fistulography and subsequent angioplasty in the confirmed obstructed sites. RESULTS Thirty-seven angioplasty procedures were performed including 32 de novo lesions and 5 restenotic lesions; of the total, 32 (86.5%) were successful. In native arteriovenous (AV) fistulas, the most common problem was inadequate flow with the lesion located within 5 cm from the AV junction (63.6%). In PTFE grafts, the most common presentation was high venous pressure with the lesion located at the PTFE-venous junction (57.1%). CONCLUSIONS Through clinical surveillance and hemodynamic monitoring during hemodialysis, failing vascular access can be detected early and treated effectively with percutaneous transluminal angioplasty.