Clinicians working in a facility specializing in cardiac care have probably seen patients with decompensated congestive heart failure (CHF) and renal failure. As a vascular access specialist, chances are that clinicians have recently been asked to provide vascular access for a relatively new treatment procedure called peripherally inserted veno-venous ultrafiltration or aquapheresis. This treatment, pioneered between 2002 and 2003, was designed for patients suffering from decompensated CHF, leading to acute fluid overload and renal failure. These patients no longer respond to the traditional diuretic and sodium-depleting therapies and often have no other treatment choices left. This article discusses the vascular access side of this treatment and the associated challenges.