Despite their propensity for significant complications, tunneled central venous catheters have become a common means of vascular access in the United States for patients requiring maintenance hemodialysis for end-stage renal disease (ESRD). Reasons for their use include advanced patient age, peripheral vascular disease (arterial and venous), late referral for creation of vascular access, and more importantly, the lack of an interdisciplinary service line on vascular access among vascular surgeons, radiologists, and nephrologists. This review article summarizes complications commonly encountered in dialysis patients who use tunneled central venous catheters for vascular access-mainly thrombosis, stenosis, and infection. Special attention is given to novel approaches for the prevention of catheter-associated infections. Effective prevention and timely treatment of common catheter-associated complications can reduce the substantial morbidity associated with the use of these devices. However, these measures should not detract from the goal of avoiding or limiting the long-term use of catheters, thereby optimizing vascular access management by ensuring the timely availability of functioning arteriovenous fistulas.