The establishment of a functional trouble-free vascular access continues to be the goal for patients with end-stage kidney disease (ESKD) who are hemodialysis (HD) dependent. Focused initiatives have been implemented in adults with an emphasis on central venous catheter (CVC) avoidance, with a move toward a higher arteriovenous fistula (AVF) placement rate.1,2 It is well known that AVFs are much more reliable than CVCs, with improved dialysis delivery (blood flow rate and Kt/Vurea) and fewer complications (need for access maintenance interventions and markedly lower infection rates).