BACKGROUND: The correct placement of large-bore venous catheters plays an important role in the management of haemodialysis patients. Whilst the procedure for landmark-based placement of these catheters is well known, the technique is not without significant morbidity and mortality. Complications include arterial puncture, haematoma, and pneumothorax. The procedure may be further complicated in these patients by venous thrombosis and abnormal vein position from multiple previous attempts at venous access. METHODS: Data on the use of ultrasound guidance versus anatomical landmarks for the placement of internal jugular vein (n = 69) and femoral vein (n = 30) dialysis access was retrospectively analysed over a 13-month period. Data collected included age, sex, duration on dialysis, number of vein cannulation sets required, number of attempts for successful cannulation, salvage of failed cannulation using landmark-based technique by ultrasound guidance, and the complication rate. RESULTS: Internal jugular vein cannulation using ultrasound was ultimately successful in 96.7% compared to 82% in the landmark group. The vein was entered on the first attempt in 83.3% of patients with ultrasound compared to 35.9% of the landmark group (P < 0.0001). Seven patients in whom the landmark technique was unsuccessful had access placed under ultrasound guidance. There were fewer carotid artery punctures in the ultrasound group (7.7 versus 0%, P = n.s.). In the femoral vein group, the vein was entered on the first attempt in 85.7% of patients with ultrasound compared to 56.25% of the landmark group (P = n.s.). CONCLUSIONS: The use of ultrasound guidance is associated with fewer complications and is more likely to lead to cannulation of the vein at the first attempt in haemodialysis patients.