Hemodialysis access is the 'life line' for patients on renal replacement therapy. Vascular access failure and complications are the second leading cause for hospitalization of patients on hemodialysis. The concept of access monitoring is based on the basic tenet that identification of patients at risk of developing future access failure, coupled with elective intervention will decrease the incidence of hemodialysis access failure and improve patient outcomes. Clinical monitoring and surveillance techniques are very effective in detecting hemodialysis access lesions. However, the studies analyzing the impact of monitoring and surveillance have yielded a variety of controversial results, which is likely the result of the differences in methodology and use of a variety of parameters. Despite the controversy surrounding the value of monitoring and surveillance, the Conditions of Coverage for dialysis providers mandate monitoring with appropriate and timely referrals to achieve and sustain vascular access. This review discusses pros and cons of various monitoring and surveillance techniques and suggests a strategy based on current literature.