The National Kidney Foundation Dialysis Outcomes Quality Initiative Clinical Practice Guidelines for Vascular Access (DOQI) have defined the access-related care for patients with end-stage renal disease (ESRD). However, the standard of care across the country has fallen short of the DOQI targets. One potential explanation for these shortcomings is the lack of compelling evidence in the literature to support the recommendations. This study was designed to compare the DOQI with the best available evidence in the literature for four clinical questions relevant to the hemodialysis access surgeon: the choice of access type (autogenous versus prosthetic), the type of prosthetic graft, management of the "failing" (nonthrombosed) access, and management of the thrombosed access. The electronic literature databases MEDLINE and Evidence-Based Medicine Reviews were searched and relevant randomized controlled trials or meta-analyses were identified for review. No randomized controlled trials comparing autogenous to prosthetic accesses were identified. However, a recent systematic review reported that the patency rates for upper extremity autogenous accesses were superior to their polytetrafluoroethylene (PTFE) counterparts. The identified randomized trials suggested that the patency rates for the different types of commercially available prosthetic grafts used for access appear comparable. They suggested that standard wall PTFE thickness and prosthetic anastomotic cuffs may be associated with better graft patency, while venous cuffs may be associated with worse patency. Furthermore, the trials suggested percutaneous angioplasty of "failing" prosthetic accesses with greater than 50% stenoses did not appear to improve patency and that routine use of intraluminal stents, as an adjunct to angioplasty, was not beneficial. They did suggest that patency after open surgical revision of "failing" prosthetic accesses was superior to that after percutaneous angioplasty. Lastly, the identified trials suggested that the patency rates after open surgical revision of thrombosed prosthetic accesses was better than after endovascular treatment. Despite the magnitude of hemodialysis-related access problems, the quality of the evidence supporting the clinical decisions relevant to the access surgeon is limited and further clinical trials are justified.