Vascular access continues to be a management challenge for nephrologists. Intravascular ultrasound (IVUS) is a tool that has been used in cardiology to obtain intraluminal imaging that can lead to better assessment of lesion morphology, composition of tissues, and adequacy of intervention such as precision of stent placement. Past reports have explored this tool in hemodialysis vascular access but owing to its expense and inconvenience, it is not routinely used. Here, we present a commonly encountered case where IVUS provided additional information to assist in decision making on management. More studies are needed to define the role of IVUS in hemodialysis vascular access.