We read with interest the article from Pisoni et al1 focused on international differences in the location and use of arteriovenous accesses for hemodialysis. The large shift from predominantly lower- to upper-arm arteriovenous fistula (AVF) creation in the United States raises the question of whether this may place patients at greater risk for exhausting available sites for future AVF creation if needed.1 Our view is that the longest patient survival without loss of vascular access options, not primary patency, should be the priority.