Hemodynamic considerations in arteriovenous vascular access modalities for hemodialysis

The Journal of Cardiovascular Surgery, vol. 66, pp. 3–16

Abstract

Arteriovenous fistulas and arteriovenous grafts are the most commonly used vascular access for hemodialysis in patients with end-stage chronic kidney disease. However, both methods face significant challenges due to the hemodynamic disturbances induced by the arteriovenous anastomosis. This causes changes in vascular structure and blood flow velocity near the anastomosis site after the fistula/graft surgery, and introduces abnormal wall shear stress and cyclic stretch. This leads to endothelial cell dysfunction, vascular smooth muscle cell proliferation, and adverse remodeling. The resulting effects include low patency rates due to vascular stenosis caused by intimal hyperplasia and insufficient outward remodeling. Additionally, the high flow conduit has been linked to adverse cardiac remodeling. To address this, various strategies have been explored to correct these localized hemodynamic abnormalities, aiming to improve long-term patency rates. In this review, an overview is provided of the current surgical techniques, anastomosis types, anastomosis angles, external scaffolds, modified fistula designs, and types of grafts. It evaluates the impact of these approaches on local hemodynamics in the access conduit and their potential effects on patient outcomes.

Authors 7

1. Nicholas A. White corresponding Aachen Department of Internal Medicine Department of Internal Medicine

   Leiden University · Leiden University Medical Center · Delft University of Technology

   Affiliation as printed

   Department of Biomechanical Engineering, Delft University of Technology, Delft, the Netherlands - n.a.white@lumc.nl

   Department of Internal Medicine, Leiden University Medical Center, Leiden, the Netherlands - n.a.white@lumc.nl

   Department of Internal Medicine, Leiden University Medical Centre, Leiden, the Netherlands - n.a.white@lumc.nl

2. Zhuotao Xiao Aachen Department of Internal Medicine Department of Internal Medicine

   Leiden University · Leiden University Medical Center · First Affiliated Hospital of Soochow University

   Affiliation as printed

   Department of Internal Medicine, Leiden University Medical Center, Leiden, the Netherlands

   Department of Nephrology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China

   Department of Internal Medicine, Leiden University Medical Centre, Leiden, the Netherlands

3. Eduard Pierre de Winter Aachen Department of Surgery, Leiden University Medical Center Department of Surgery, Leiden University Medical Centre

   Leiden University · Leiden University Medical Center

   Affiliation as printed

   Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands

   Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands

4. Mohan Li Aachen Division of Endocrinology Department of Medicine, Einthoven Laboratory of Experimental Vascular Medicine

   Leiden University Medical Center

   Affiliation as printed

   Division of Endocrinology, Department of Medicine, Einthoven Laboratory of Experimental Vascular Medicine, Leiden University Medical Center, Leiden, the Netherlands

5. Margreet R. de Vries Aachen Department of Surgery, Leiden University Medical Center Department of Surgery, Leiden University Medical Centre

   Leiden University · Leiden University Medical Center

   Affiliation as printed

   Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands

   Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands

6. Koen E.A. van der Bogt Aachen Department of Surgery, Leiden University Medical Center Department of Surgery, Leiden University Medical Centre

   Leiden University · Leiden University Medical Center · Medisch Centrum Haaglanden · Stichting Haaglanden Medisch Centrum

   Affiliation as printed

   Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands

   Haaglanden Medical Center, The Hague, the Netherlands

   University Vascular Center West, The Hague, the Netherlands

   Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands

   Haaglanden Medical Centre, The Hague, the Netherlands

7. Joris I. Rotmans Aachen Department of Internal Medicine Department of Internal Medicine

   Leiden University · Leiden University Medical Center

   Affiliation as printed

   Department of Internal Medicine, Leiden University Medical Center, Leiden, the Netherlands

   Department of Internal Medicine, Leiden University Medical Centre, Leiden, the Netherlands