Autogenous arteriovenous fistula (AVF) is the vascular access of choice for hemodialysis. However, primary failure after fistula surgery occurs frequently, mainly in the form of venous neointimal hyperplasia (NIH). As a result, the main challenge to promote AVF maturation is the inhibition of venous NIH to maintain patency of the fistula. This article reviews the pathophysiology of AVF and summarizes the potential therapeutic approaches to inhibit venous NIH in AVF and to promote maturation of the endovascular fistula.