The creation and long-term management of dialysis accesses has been and remains a challenging aspect of vascular surgery practice. Until recently, vascular surgeons relied on open techniques to salvage and maintain dialysis fistulas and grafts. In the last 10 years, percutaneous approaches have become widely adopted and to this day continue to be refined as new devices and techniques are developed. Recent series have found similar technical success rates to open surgery, with the best results seen in the treatment of short-segment and anastomotic stenoses. Percutaneous interventions also allow for treatment of remote and surgically inaccessible lesions such as central vein stenoses. Some of the pitfalls of this approach include the exposure to thrombolytics, intravenous contrast, and radiation. Nevertheless, despite these limitations, a percutaneous approach has become first-line therapy in dialysis access management.