Vascular access procedures and associated complications are a major cause of morbidity and increasing health care cost in patients undergoing hemodialysis. Preoperative sonographic evaluation can alter surgical planning and increase the success of autogenous arteriovenous fistulas (AVFs). Ultrasonography may serve as a surrogate for AVF maturation. Studies disagree whether close access monitoring with early detection and intervention improves access longevity. Evaluation of the problem AVF and the synthetic arteriovenous graft, assessing for stenosis or other treatable causes of AVF nonmaturation and graft dysfunction, has been described. This review describes sonographic approaches for hemodialysis access planning and subsequent access assessment. © 2011 Elsevier Inc. All rights reserved.