Dialysis as a therapy has become nearly universally available and the ability to provide dialysis and dialysis access over long periods of time has become well established. Unfortunately, technology has yet to provide the perfect dialysis access conduit, one which will not stenose, thrombose, or be prone to infection. Native cephalic vein remains the superior dialysis conduit even 30 years after it was first described. At present, the emphasis in constructing dialysis access must be to attempt to reserve native vein, both in the arm and centrally. The most important decisions remain the ones made at the initiation of dialysis: avoiding subclavian catheters that may lead to subclavian vein stenosis and loss of that extremity for later access; nephrologists making every effort to shelter one extremity for later access formation in the patient who presents with signs of eventual need for dialysis; and if at all possible constructing a native fistula, either forearm or upper arm, which will serve the patient better in the long term, rather than the simpler course of placing a prosthetic graft. Dialysis access planning may need to look 15 to 20 years into the future for the patient who, if not a potential transplant candidate, may remain on dialysis for a very long time. The ability to keep dialysis access functional has improved markedly with the evolution of radiologic methods for thrombolysis and intervention. However, as in other areas of surgery performing the best operation first and avoiding complications is the path that best serves the patient.