The aim of the paper is to review surgical options in problematic arteriovenous haemodialysis access—in particular, to explore and discuss some surgical alternatives to interventional radiology in the case of failing, failed or complicated arteriovenous access. There is copious evidence to support endovascular techniques to treat non-maturation, stenosis, thrombosis and other complications of arteriovenous access. However, there may be times when the surgery-first approach might be a useful adjunct, alternative or even preferable, including the creation or revision of an anastomosis in the forearm, which may yield better patency rates than endovascular intervention. The creation and maintenance of haemodialysis access can be a complex process and the surgeon and the interventional radiologist should work closely together. The distinct roles of the surgeon and the interventional radiologist in the treatment of a problematic arteriovenous access remain debatable and the authors suggest a multidisciplinary team approach when planning treatment of access complications, which may require repeated interventions.