Background/Aims: This study aims to demonstrate whether the association between initial vascular access and mortality among hemodialysis patients varies by age. Methods: We conducted a retrospective study that included 2,552 patients who started hemodialysis. Of the initial sample, 507 patients who did not survive the first 3 months after initiation of hemodialysis were excluded. Vascular access was divided into three categories: percutaneous catheter, tunneled cuffed catheter, and arteriovenous (AV) access. Results: Survival rates for patients who received a central venous catheter, such as percutaneous or tunneled cuffed catheter, aged 65-74 years and those ≥75 years were reduced, but not for those aged <65 years (log rank p<0.001, 0.007, and 0.278). After fully adjusting for potential confounding factors in the patients aged <65 years, percutaneous and tunneled cuffed catheter were not associated with 5-year mortality. On the other hand, for patients aged 65-74 or ≥75 years, percutaneous catheter and tunneled cuffed catheter were associated with higher 5-year mortality rates. As age increased, the conversion rate from central venous catheter, including percutaneous catheter and tunneled cuffed catheter, to AV access decreased (94.1%, 90.5%, and 80.3% for patients aged <65 years, 65-74 years, and ≥75 years, respectively; p<0.001). Conclusion: In patients aged <65 years, if conversion from central venous catheter to AV access was performed properly, initial vascular access was not associated with long-term mortality. Therefore, it is prudent to begin hemodialysis with an available central venous catheter rather than delay dialysis in favor of vascular access. We suggest that a “fistula first” strategy is superior for elderly patients and demonstrates that it is desirable to change to AV access, and not maintain an initial central vascular catheter.