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Vascular steal remains a significant cause of morbidity after placement of access for hemodialysis and has been reported to occur at an incidence of 2-8%. The purpose of this study was to identify which factors may predict the development of steal. A retrospective review of new-access placement over a three-year period revealed 275 procedures on 129 patients. There were 225 (82%) prosthetic conduits and 50 (18%) native fistulas placed. Thrombectomies and revisions were excluded. There were 23 cases (8.4% incidence by access) of steal in 19 patients (15% incidence by patient). The consequences of steal included development of a Volkmann's contracture in 4 patients despite ligation of the access in 3, gangrene with loss of digits in 2 patients, decreased motor function in 3 patients, and refusal of dialysis and subsequent death in 1 patient. Five patients had mild symptoms that resolved spontaneously. Thirty-nine percent (n = 9) of the steal cases occurred in second- and third-access placements. By univariate analysis the factors that predicted steal were increased age (63.1 ± 14 years versus 52.0 ± 16.2 years; P = 0.002), female sex (14.4% in women compared with 1.6% in men; P = 0.003). Diabetes mellitus was also more prevalent (12.3% compared with 3.4% in non-diabetics; P = 0.08) but did not reach statistical significance. There was no relationship to type of access performed, conduit used, and location. When combinations of these factors are fitted to a multivariate logistic regression, the best combination results in only 19% of the variation in outcome (steal) being explained (r = 0.43; P = 0.001). Vascular steal remains a common, serious cause of morbidity in dialysis access placement. Although it is more common in elderly diabetic women, accurate prediction based on clinical variables alone is not possible. [ABSTRACT FROM AUTHOR]