Over the past 40 years, improvements in vascular access management have enhanced patient outcomes and decreased an epidemic of access failure. Arteriovenous fistulae are again the access of choice and new percutaneous therapies and outpatient access centers have revolutionized the therapeutic approach to access failure. Evidence-based guidelines, supported by national and international outcome data have helped rationalize vascular access care. Current challenges and, in particular, the increased use of catheters with resultant increases in patient morbidity and mortality must be rapidly addressed to protect patients and decrease the unacceptably high rates of catheter-related infection. Future technologies will continue to improve vascular access management. Our ability to utilize these new approaches to benefit patients will depend on appropriate application, continued development of standardized delivery systems utilizing outcome measures and payment systems that support and incent outcome improvement.