This article reviews current concepts in the percutaneous management of thrombosed polytetrafluoroethylene (PTFE) dialysis access grafts. The maintenance of dialysis access grafts remains a challenging task. Graft surveillance is critical in the prevention of graft thrombosis to prolong graft survival. Once a graft is thrombosed, surgical and percutaneous options are available for restoration of flow. There has been an evolution in the percutaneous treatment of thrombosed dialysis access grafts during the last 20 years, with refinement of pharmacomechanical techniques, allowing for safe and efficacious restoration of flow in thrombosed grafts. There has been emergence of alternative thrombolytic agents to urokinase, which was withdrawn from the United States in late 1998 and recently reintroduced. These alternative thrombolytic agents have similar outcomes compared with urokinase, with the additional advantage of being less expensive. In addition, several mechanical devices, which were popular briefly when urokinase was unavailable, are available currently for use within grafts, with similar success, although their prices have limited widespread use.