**1. Introduction**

Patients with end stage renal disease (ESDR) on maintenance hemodialysis (MHD) need vascular access to start and continue hemodialysis (HD) as a Renal Replacement Therapy. The Creation and maintenance of vascular access (VA) is a difficult task. With increased references related to VA to radiology department, we face several complications related to preoperative mapping, early postoperative maturity issues along with delayed complications related to VA. We have tried to address issues related to VA formation and maintenance along with providing basic information related to pre and postoperative duplex Ultrasonography (USG). Preoperative Ultrasonography aids to physical examination where patient criteria like obesity, history of access failure, vascular diseases and otherwise difficult examination hinder the clinical assessment of vessels for VA. Development of stenosis or thrombosis leading to failure or immaturity of VA is the main threat in postoperative period. Duplex Ultrasonography allows proper identification of cause of VA failure. Volume flow <500 ml/min or > 50% stenosis correlate with formation of thrombosis within 6 months [1]. Presence of co-morbidity like diabetes and peripheral vascular disease in most of ESRD patients and the always changing local hemodynamic factors complicate the VA commonly. Hence, imaging plays a major role in pre and post operation period for rapid diagnosis and management of VA related complications.
