Introduction: Increase the need for hemodialysis (HD) due to concomitant increase incidence of nephropathic disease in association with increase in patients' life expectancy in the last three decades, makes it necessary to establish secondary or tertiary dialysis access to overcome exhausted peripheral veins and central venous occlusion.The increase of patients' life expectancy, with the limited durability of these angioaccesses, increases the demand to repeat fistula construction at different upper extremity levels (wrist, forearm, upper arm) and can ultimately result in exhaustion of autogenous AVF.(3) Methods: We conducted an analysis of prospectively collected data over a 3-year period in between December 2014 and December 2017 for 45 patients (32 men, 13 women) with ESRD who underwent infraclavicular arterio-arterial chest wall prosthetic graft procedures as a permanent vascular access for hemodialysis. After the local hospital’s ethical and scientific committee approved the study protocol, patients were enrolled at Vascular Surgery Unit, Benha University/Department of Surgery, Vascular Surgery Department, Nile Insurance Hospital & Vascular Surgery Department, Helwan University. An IAALG procedure was indicated only for patients who had no suitable superficial cephalic and basilic veins for an AVF and who belonged to one of the following indication:1.Cardiac insufficiency that was refractory to medical therapy confirmed by echocardiography based ejection fraction ≤ 40%.2.The unsuitability of large six deep veins (the subclavian, internal jugular and femoral veins). A vein was considered unsuitable when an occlusion or high-grade long stenosis (<70% in diameter, >4 cm long) of the venous outflow was detected and could not be treated by any interventions.3.Patients with at least one patent central vein that should be preserved as bailout access for an emergency central venous catheter (CVC). Results: The primary patency rates were 100%, 97.7%, 93%, 77.5% and 73.7% at 6, 9, 12, 18, and 24 months, respectively. The secondary patency was 100%, 88.7%, and 66.6% at 6, 9, and 12 months, respectively, after successful thrombectomy in nine patients. There were 20 (44.4%) secondary variable procedures performed during follow-up period Eighteen (40%) patients required 20 secondary procedures due to complications. The most common complication was graft thrombosis; it occurred in 11 patients (24.4%), surgical thrombectomy done in 9 (20%) patients, the other two thrombosed grafts were secondary to late graft infection that necessitate grafts removal. Puncture site aneurysm occurred in 7 cases (15.6%) with no procedure related mortality or limb threatened conditions were documented in our study. Conclusion: our case study reports reasonable mid-term patency and complications associated with this pattern of vascular access show that Infraclavicular arterio-arterial axillary loop grafts are a valid alternative option for complex patients. We advocate the use of this technique in patients with exhausted all vascular access possibilities in both upper extremities with central venous obstruction. We also indicate it in case of patients with cardiac insufficiency that could not tolerate long-term hemodynamic effect of arterio-venous fistula / graft.