The widespread use of percutaneous angioplasty for venous stenoses has lengthened the functional life span of hemodialysis access, while preserving precious venous capital. A subset of dialysis patients with dysfunctional access sites will harbor stenoses which are intractable, in that they fail to respond to conventional balloon angioplasty or recur in the weeks following angioplasty. This editorial discusses various endovascular approaches to the management of intractable venous stenosis as well as promising future therapies.