The number of patients requiring hemodialysis is continuously increasing around the world. Hemodialysis affects patient quality of life and it is also associated with a higher risk for cardiovascular events. In addition to traditional risk factors for cardiovascular events such as hypertension, hyperlipidemia, and diabetes, hemodialysis is associated with hyperphosphatemia, chronic inflammation, vascular calcification, and anemia which accelerate atherosclerosis, vascular stiffness, and cardiac ischemia. Treatment strategy for coronary revascularization in this progressive disease remains controversial. However, a systematic treatment including medical therapy and complete revascularization through a less invasive strategy should be considered in addressing this problem. This review discusses the epidemiology, vascular pathology and current treatment options in patients with end-stage renal disease requiring coronary revascularization.