When significant improvements in life expectancy and quality of life have been made in patients on hemodialysis, it is not uncommon for surgeons to be confronted with patients who have “outlived” their arteriovenous (AV) access options in the upper extremities. To meet this challenge, the access surgeon must have a number of complex vascular access procedures in his or her surgical armamentarium and must be aware of the advantages and disadvantages of each. We offer theraputic options for complex hemodialysis access placement including venous translocation and transposition.