Progress in the development of permanent vascular access for hemodialysis has been much slower than progress in other areas of end-stage renal disease (ESRD) patient care. This article provides a brief historical overview of the major means used for vascular access since the start of chronic hemodialysis. These access modalities include external shunts, arteriovenous fistulae, prosthetic arteriovenous grafts, needle-less access devices, and tunneled central venous catheters. Despite the evolution of access methodology, vascular access complications remain a major impediment to the full rehabilitation of the chronic hemodialysis patient.