Purpose of Review <p>Herein we sought to review current strategies, evidence, and evolving technologies for the maturation and long-term maintenance of hemodialysis access in patients with end-stage renal disease.</p> Recent Findings <p>Preserving functional arteriovenous access requires multidisciplinary coordination, evidence-informed decision-making, and adaptability as technology and clinical experience continue to evolve.</p> Summary <p>Areas for future research include identifying additional adjuncts to facilitate access maturation; determining the optimal angioplasty strategies for durable patency; defining best practice approach for thrombosed access salvage as well as further interrogating the long-term cardiopulmonary consequence of recurrent access thrombectomies; evaluating evolving drug delivery technologies to mitigate neointimal hyperplasia; developing machine learning algorithms to predict access dysfunction based on hemodialysis machine data with subsequent alerts to inform personalized interventions; assessing the biomechanical impact of various cannulation techniques on long-term access function and using this information to inform best practice in an effort to standardize access maintenance.</p>