Preserving the Dialysis Lifeline: An Updated Review on Central Venous Stenosis

Central venous stenosis (CVS) is an under-recognized yet clinically consequential complication of hemodialysis care, threatening vascular access function, limiting future access options, and contributing to substantial morbidity in patients with end-stage kidney disease. Although often detected only after access dysfunction or venous hypertension becomes clinically apparent, CVS represents the cumulative consequence of biologic, mechanical, and hemodynamic injury to the central venous circulation. In this narrative review, we synthesize current evidence on the epidemiology, pathobiology, risk factors, diagnosis, and management of CVS in hemodialysis patients, with emphasis on translational links between venous injury and clinical access failure. Central venous catheters, cardiac implantable electronic device leads, peripherally inserted central catheters, and high-flow arteriovenous access can initiate endothelial disruption, inflammation, thrombosis, and maladaptive neointimal hyperplasia. These processes are amplified by the uremic milieu, oxidative stress, impaired endothelial repair, and vascular smooth-muscle cell activation, providing a mechanistic basis for recurrent stenosis after intervention. Diagnosis requires integration of clinical suspicion with imaging, including duplex ultrasound, CT or MR venography, and catheter-based venography, which remains the procedural reference standard and enables immediate treatment. Endovascular therapy, particularly percutaneous transluminal angioplasty with selective stent placement, remains the cornerstone of management for symptomatic disease; however, elastic recoil, restenosis, and repeated reintervention continue to limit long-term durability. Emerging strategies, including drug-coated balloons, intravascular ultrasound-guided intervention, dedicated venous stents, and biologically targeted approaches, may improve outcomes but require further validation. Prevention through catheter avoidance, optimal device planning, early recognition, and multidisciplinary access stewardship remains central to preserving the hemodialysis lifeline. A mechanism-informed approach to CVS may help shift care from repeated salvage toward durable access preservation.