The type of hemodialysis vascular access (fistula, graft, catheter) employed plays an important role in the results of dialysis treatment. Moreover, different complications can affect the vascular access and interfere with the morbidity and mortality of patients. The ideal vascular access is the Cimino Brescia fistula, followed by graft. Tunnelled central venous catheters should be considered as 'second choice' because they present a higher incidence of complications, mainly due to thrombosis and infections. Finally, in elderly patients the vascular bed is frequently damaged and this may make it difficult to create a Cimino (Brescia) fistula (AVF). The use of instrumental tests, as echo-color Doppler or angiography in order to evaluate the real status of vascular bed in elderly patients can offer a great opportunity in order to find the best position where it is possible to create a fistula or graft. We suggest that a native fistula can be easily created in elderly patients and the 'second choice' access should be limited to a small proportion of patients. Although patient selection is important, even patients of 80 years or older who are considered suitable for surgical placement of access should not be denied an AVF solely because of age. Nephrologists or vascular surgeons, who create vascular access, should develop a good patient and site selection to predict which vascular access will function successfully rather than risk complications of prolonged central catheters.