From Acute Thrombosis to Eccentric Neointima in Arteriovenous Fistula

Thrombosis is a central driver of both early and late arteriovenous fistula (AVF) failure. While symptomatic thrombosis contributes to early AVF occlusion and is treated promptly, the role of asymptomatic mural thrombi in human AVF remains poorly understood. Indirect evidence suggests that these thrombi contribute to late juxta-anastomotic neointimal hyperplasia, luminal stenosis, and AVF failure. Using complementary mouse and rat AVF models, we recently demonstrated the interplay between disturbed arteriovenous (AV) flow, acute AV thrombus, and eccentric and heterogeneous neointimal lesions. These studies indicate that thrombus formation and organization are not merely acute events, but active modulators of juxta-anastomotic remodeling, highlighting the critical role of early thrombosis in AVF maturation and failure. This review summarizes recent advances in understanding the mechanistic role of thrombosis in AVF remodeling, stenosis, and access failure, providing insight into potential strategies to improve vascular access outcomes.