Background: Arteriovenous fistula (AVF) is the standard access for hemodialysis in end-stage renal disease (ESRD) patients on maintenance hemodialysis. Because of the higher rate of morbidity and mortality associated with central venous catheter (CVC), it should be used after exhaustion of all AVF options. Sometimes, insertion of CVC is very difficult or impossible even with radiological guidance due to central venous obstruction. Therefore, a category of patients with multi-access failure and central venous obstruction requires a reliable alternative access. Since arterio-arterial prosthetic loop (AAPL) was introduced as an access for hemodialysis with encouraging results, in the present study we studied the use of axillary-axillary AAPL for patients with multi-access failure and unsuitable for conventional vascular access. Aim of the work: Evaluation of the early results of axillary arterio-arterial synthetic loop as a vascular access for hemodialysis in ESRD patients with multi-access failure. Patients and methods: Twenty ESRD adult patients on maintenance hemodialysis with multi-access failure and unsuitable for conventional vascular access underwent Axillary arterio-arterial prosthetic loop procedure for hemodialysis. All patients were assessed preoperatively by duplex ultrasonography for the targeted upper limb. Polytetrafluroethylene (PTFE) graft was interpositioned in the end to end manner to the ends of the axillary artery after exposure of the artery through infraclavicular incision and creation of a subcutaneously looped tunnel on the chest wall. All patients received acetylsalisyslic acid indefinitely after the operation and puncture of the graft was allowed after 2 weeks. All patients had regular follow up visits for 6 months to assess the AAPL as regards: wound care, records from dialysis unit and exclude complications. Results: The indications for creation of AAPL included multi-access failure with no possibility to create native AVF or AVG in 17 patients (85%), while steal syndrome was the indication in 2 patients (10%) and heart failure in 1 patient (5%). The mean operative time was 120 minutes (ranging from 90 to 140 minutes). The median length of hospital stay after the procedure was 4 days (ranging from 2 to 5 days) and the perioperative mortality rate at 30 days was 5 %. The median access flow at rest was 200 ml/min (150 – 300 ml/min) at 1 month postoperatively, with no significant difference at 3 and 6 months. Primary and secondary patency rates at 6 months were 80% and 90% respectively. Access thrombosis occurred in 3 patients with mild hand ischemia and the graft was salvaged 2 patients, while in the third patient the graft was severely lacerated and was ligated. Severe infection was encountered in one patient with secondary hemorrhage which necessitated graft excision and ligation of the axillary artery with compensated upper limb. Conclusion: Axillary arterio-arterial prosthetic loop can be considered as an alternative procedure for hemodialysis in ESRD patients with multi-access failure and occlusion of central veins. Key words: vascular access – arterioarterial prosthetic loop – hemodialysis.