Recent Innovations and Advances in Arteriovenous Fistula Creation: A Narrative Review

Arteriovenous fistulae (AVF) are the gold standard for vascular access among patients requiring hemodialysis; however, AVF have high primary failure rates. Novel approaches and technologies to improve AVF patency include modifications to open approaches, such as the radial artery deviation and reimplantation fistula, and percutaneous approaches, such as the endovascular AVF. Despite these advances, these modifications are limited in reducing neointimal hyperplasia, stenosis, or thrombosis, and thus have limited capacity to improve AVF maturation and utilization; as such, vascular access requires continued innovation. Emerging strategies to prevent neointimal hyperplasia include drug-embedded and bioresorbable perivascular wraps. Increased rates of AVF failure among women highlight sex differences in the biology of AVF maturation and suggest additional targets to improve outcomes. Other advances in understanding the biology of AVF maturation suggest potentialized approaches for patients, including immune system modulation and stem cell therapies. Although these emerging technologies may improve AVF maturation and utilization, longer-term patency and freedom from complications such as central vein stenosis and dialysis access associated distal ischemia emphasize the critical need for continued scientific inquiry and technological development to optimize vascular access.