VA serves as a lifeline for HD patients. VA-related expenditures are the largest component of dialysis-related costs. Wide variations in VA practices and outcomes around the world have emerged from analysis of the DOPPS data. Both patient and practice pattern-related factors determine type of VA placed as well as VA outcomes. Type of VA is associated with patient survival after adjustment for case mix. A multidisciplinary approach is crucial for success of any VA program with emphasis on pre-ESRD planning and implementation. AVF should serve as the gold standard. Use of catheters should be minimal, but this will likely remain a challenge for some time. Observational data suggest that earlier cannulation of AVF may not be as deleterious as previously thought. Clinical trials are sorely needed in many aspects of VA management to improve both VA and patient outcomes.