Hemodialysis vascular access dysfunction remains a major cause of morbidity and repeated interventions. Stenosis related to neointimal hyperplasia and altered hemodynamics leads to access flow limitation and thrombosis, particularly in AVFs. While percutaneous transluminal angioplasty is the standard first-line treatment, durability is often limited, resulting in frequent reinterventions. Drug-coated balloons, most commonly paclitaxel-based, have been introduced to inhibit restenosis and have demonstrated improved target lesion patency compared with conventional balloon angioplasty in several randomized trials, though outcomes vary by lesion location and study design. This narrative review summarizes the current evidence for drug-coated balloon angioplasty in dysfunctional arteriovenous access, discusses key trial endpoints, reviews safety and practical considerations, and highlights ongoing controversies and future directions.