KDOQI guidelines for vascular access 2019 divides complications of vascular access into the three categories; thrombotic flow–related complications, non–thrombotic flow–related complications, infectious complications. These are suspected and evaluated by monitoring and surveillance for vascular access and confirmed by imaging study whether it is clinically significant or not. A clinically significant lesion is one that contributes to clinical signs and symptoms without other cause (with or without a change in surveillance measurements, such as change in blood flow [Qa] or venous pressures). KDOQI guidelines states that it is reasonable to use balloon angioplasty as primary treatment of AVF and AVG stenotic lesions that are both clinically and angiographically significant, and suggests the appropriate use of self-expanding stent-grafts in preference to angioplasty alone to treat clinically significant graft-vein anastomotic stenosis in AVG. KDOQI suggests that the use of an appropriately placed stent-graft is preferred to angioplasty alone for the treatment of in-stent restenosis in AVG and AVF, whereas recommends avoiding the use of bare metal stents for the treatment of significant AVG and AVF stenotic lesions. Open surgical repair is generally reserved for recurrent lesions, those not amenable to endovascular treatment, and those for which the outcomes associated with the endovascular approach are poor. Thrombosed AV access can be tried by either surgical or endovascular treatment, but it is reasonable to surgically treat a failing AV access in the cases of endovascular treatment failure, clinically significant lesions not amenable to endovascular treatment, and situations in which the surgical outcomes are deemed markedly better. For infected AV access, the rapid initiation of empiric broad-spectrum antibiotics and timely referral to a surgeon is emphasized. It is important that the specific surgical treatment for AV access infections (with concurrent antibiotics) should be based on the patient’s individual circumstances considering the extent of infection, offending organism, and future vascular access options. Definitive surgical treatment of AV access infection requires careful individualized consideration of the extent of the infection, the offending organism, the type of AV access (ie, AVF vs AVG), the location of the infection (ie, anastomotic vs nonanastomotic), the extent of the infection (ie, localized vs diffuse), the presence of systemic signs, the presence of bleeding, and, importantly, future dialysis access options. Both AVF and AVG infections can lead to erosion of the skin and life-threatening hemorrhage, underscoring the importance of a timely, definitive surgical treatment as needed. AV access salvage options include those for in situ and extra-anatomic reconstruction (with the reference being the anatomic course of the infected AV access) for localized infections, where close follow-up and surveillance are mandatory, given the risk of recurrent infection and the potential for anastomotic disruption and significant bleeding. The presence of an aneurysm/pseudoaneurysm alone in the absence of symptoms is not an indication for definitive treatment. However, an aneurysm/pseudoaneurysm that is considered at risk of complications is one with evidence of associated symptoms or skin breakdown, and it is reasonable to obtain emergent surgical assessment and treatment for AV access aneurysm/pseudoaneurysm complications such as erosion or hemorrhage. It is recommended to avoid cannulating the access segment(s) that involve the aneurysm/pseudoaneurysm if there are alternative sites. Surgical management is the preferred treatment for patients with symptomatic, large, or rapidly expanding AV access aneurysm/pseudoaneurysm, and a definitive surgical treatment is usually required for anastomotic aneurysms/pseudoaneurysms. Covered intraluminal stents (stent-grafts) as an alternative to open surgical repair of AV access aneurysms/pseudoaneurysms only in the special circumstances such as patient contraindication to surgery or lack of surgical option. Moderate (Intermittent symptoms during dialysis, claudication) to severe (Ischemic rest pain, tissue loss) signs and symptoms of steal syndrome often require urgent treatment to correct the hemodynamic changes and prevent any longer-term disability. signs and symptoms consistent with AV access steal should be referred urgently to a surgeon/interventionist familiar with the diagnosis and options for the definitive treatment of AV access complications, particularly AV access steal. It is recommended to closely monitor and prophylactically manage AV access with high flows to avoid serious or irreversible complications (eg, high output cardiac failure). Close monitoring refers to physical exam and history on routine dialysis rounds and determination of Qa/CO every 6-12 months, or more frequently as needed. In case of dysfunctional CVCs due to thrombosis, KDOQI recommends intraluminal administration of a thrombolytic agent such as alteplase in each CVC port to restore CVC function (intraluminal administration of alteplase 2 mg preferred). when a CVC fibrin sheath is associated with adverse clinical manifestations (CVC dysfunction and/or infection), a CVC exchange with or without balloon disruption of the fibrin sheath should be performed. For all the complications of vascular access, the clinically significant lesion is recommended to be promptly treated, when further confirmatory studies reveal a culprit lesion responsible for clinical signs and symptoms.