Arteriovenous Fistula Failure in Hemodialysis: Mechanisms, Risk Factors, and Management Strategies

Arteriovenous fistula (AVF) is the most used vascular access for hemodialysis treatment due to its great long-term patency, lower infection rates, and cost-effectiveness compared to arteriovenous grafts and central venous catheters. However, Arteriovenous fistula failure remains a critical clinical issue, contributing in increasing morbidity, healthcare costs, and suboptimal dialysis outcomes. AVF failure is broadly categorized into early failure, resulting from inadequate maturation, and late failure, often due to stenosis, thrombosis, or excessive neointimal hyperplasia. This review explores the pathophysiology, risk factors, and mechanisms underlying AVF failure, including endothelial dysfunction, hemodynamic stress, inflammation, and vascular remodeling. Additionally, we examine current strategies to enhance AVF maturation and long-term functionality, such as preoperative vascular mapping, pharmacological interventions, surgical techniques, and endovascular treatments. Furthermore, emerging therapies including gene therapy, stem cell applications, and computational modeling hold promise for reducing AVF failure rates and improving patient outcomes. A multidisciplinary approach combining clinical expertise, biomedical innovations, and patient-specific treatment strategies is essential for optimizing AVF patency and ensuring effective hemodialysis access.