BACKGROUND: The population of elderly hemodialysis patients is increasing, yet the most suitable approach for providing permanent hemodialysis access remains unclear. Here we report outcomes using an approach aimed predominantly at creating radiocephalic (RC) fistulas. METHODS: A single-center retrospective cohort study was performed in which access outcomes for primary arteriovenous fistulas created between January 1, 2005, and December 31, 2012, in patients aged 70 years or older were compared. RESULTS: During the study period, 204 RC, 1 brachiobasilic, and 9 brachiocephalic (BC) primary fistulas were created initially for patients requiring dialysis. Immediate failure rates for RC fistulas were lower than for BC fistulas but not significantly so (12% vs 22%; Fisher's exact text, P = .319). One-year primary and secondary patency for RC fistulas was 54% and 66%, respectively, and similar for those created in patients between 70 and 80 years old and in those older than 80 years. The secondary patency rate at 1 year for RC fistulas using cephalic vein of diameter <2.5 mm was lower than for fistulas created with cephalic vein >2.5 mm (49% vs 72%; log-rank test, P = .005). Creation of a BC fistula was associated with a significantly higher incidence of steal syndrome than with an RC fistula (10% vs 2%; Fisher's exact text, P = .009). CONCLUSIONS: RC fistulas formed in the elderly carry a lower risk of steal syndrome than BC fistulas and offer the potential for further revision surgery, such that acceptable secondary patency is achieved for RC fistulas formed using even small (<2.5 mm) cephalic veins.