While the use of arteriovenous grafts has recently declined, there has been an astronomical increase in hemodialysis patients dialyzing with tunneled dialysis catheters (TDCs). Recent data have indicated that over 70% of the patients with end-stage renal disease initiate dialysis with a catheter. Additionally, up to 27% of the end-stage renal disease patients in the US are using TDCs as their permanent access, with placement rates having doubled since 1996. Although most modern catheters claim to provide adequate blood flow for dialysis, they are associated with the highest incidence of complications, morbidity and mortality when compared with other types of vascular access. It is for these reasons that the National Kidney Foundation Dialysis Outcomes Quality Initiative guideline 30 as well as the Fistula First Change Concept 7 emphasize limiting the use of catheters and fostering the creation of arteriovenous fistulae. Early referral has clearly been shown to minimize the use of TDCs and maximize fistulae. This report focuses on the role of additional measures that minimize TDC use, such as dialysis modality presentation and peritoneal dialysis, vascular access education, preoperative vascular mapping and salvage of early failure and thrombosed fistulae.