The approach to patients with "complex" permanent hemodialysis (HD) access problems remains poorly defined. The purpose of this review is to outline our current algorithm for patients presenting for dialysis access and to address the management of specific problems that complicate this objective of establishing permanent access. The key components of the algorithm include noninvasive imaging in the diagnostic vascular laboratory to determine all the possible access configurations and invasive imaging with both venography and arteriography to confirm the optimal choice. The specific access-related problems addressed include inadequate ipsilateral vein, inadequate arterial inflow, central vein stenosis/occlusion, multiple previous access failures, and obesity. Despite the label of "complex" access problems, it is possible to construct native arteriovenous fistulas (AVFs) in almost all patients presenting for access using the standard principles of vascular surgery that are based on establishing adequate arterial inflow, adequate venous outflow, and selecting an appropriate conduit.