Dialysis catheters represent a necessary evil for those on dialysis. Referred to as “the great white tube of death” by some, this potentially high risk means of access can be a life saver for others. The DOQI guidelines recommend that no more than 10% of permanent access be in the form of catheters. Despite these recommendations, at many centers the percentage of patients dependent on catheters is significantly higher with rates approaching 40%. Although catheters are associated with poor patency (less than 60% at 6 months), high infection rates (1–5/1,000 catheter days), high overall costs relative to functionality, and central vein destruction, they are required in many situations. These include acute renal failure, emergent presentation of chronic renal failure, bridging device for fistula or graft maturation, temporizing measure related to graft or fistula infiltration, infection or surgical revision, permanent access for those without fistula or graft options or those suffering from labile pressure, and severe hypotension.