, Introduction
Chronic kidney disease (CKD) is a global health burden with a high economic cost to health systems and is an independent risk factor for cardiovascular disease. All stages of CKD are associated with increased risks of cardiovascular morbidity, premature mortality, and/or decreased quality of life [1]. CKD is affecting more than 10% of the global population, with an estimated 800 million individuals living with the condition, making it an emerging global burden [2].
Patients with end-stage kidney disease (ESKD) require renal replacement therapy, with hemodialysis being the most prevalent dialysis modality. A functioning vascular access remains the main constraint for adequate dialysis [3,4]. The first successful maintenance hemodialysis was introduced following the breakthrough arteriovenous (AV) polytetrafluoroethylene (PTFE; Teflon) shunt creation by Quinton, Dillard, and Scribner from Seattle in 1960 [5]. Following the AV shunt creation, the patient lived for almost 11 years, marking the landmark beginning of maintenance hemodialysis. Since the advent of successful long-term dialysis treatments in the 1960s, the field of vascular access has evolved significantly, driven by innovations in surgical techniques, the availability of better materials, and a deeper understanding of access-related complications.
The evolution of vascular access can be organized into three eras:
• The pioneering surgical era, marked by early shunts and the birth of native AV fistulas.
• The biomaterial and graft era, characterized by the introduction of synthetic conduits.
• The contemporary endovascular and precision-medicine era, emphasizing minimally invasive techniques, surveillance, and individualized planning.
Together, these eras demonstrate how innovation continuously responded to clinical limitations, progressively improving durability, safety, and patient experience. This review synthesizes the historical context, current practices, ongoing innovations, geographic disparities, and future directions in vascular access care to support optimized utilization and improved quality of life for dialysis patients.
Historical milestones
The first major breakthrough in vascular access came in 1960 with the invention of the Scribner shunt by Dr. Belding Scribner and his team in Seattle. Prior to this, dialysis was restricted to acute, short-term use due to the lack of reusable and safe vascular access. The Scribner shunt (a Teflon tube connecting the radial artery and cephalic vein externally) allowed repeated access to the bloodstream, marking the beginning of chronic hemodialysis treatment [6]. While revolutionary, it had significant limitations including infection risk, clotting, and physical fragility.
In 1966, James Cimino and M. J. Brescia invented the native AV fistula (AVF) at Bronx Veterans Hospital. They made side to side anastomosis between the radial artery and cephalic vein at the wrist, making it more durable and less prone to infection and thrombosis than the Scribner shunt. The procedure gained widespread recognition after the team’s work was published in the New England Journal of Medicine [7]. The Brescia-Cimino fistula became the gold standard for hemodialysis access due to its long-term patency and lower complication rates and remains so today, particularly recommended by guidelines such as Kidney Disease Outcomes Quality Initiative (KDOQI) and renal association [8,9].
The next challenge was patients who were unsuitable for native AVF. In 1970s AV graft (AVG) emerged. Sparks [10] created the first AVG, using a mandril graft which consisted of a silicone rubber rod covered with two specially prepared siliconized knitted Dacron tubes. Later, two materials became widely used in the vascular surgery field: bovine and expanded PTFE (ePTFE) graft. Both were easy to handle, did not form aneurysms after repeated cannulation, and had low infection rates, therefore quickly becoming the standard option in patients unsuitable for AVF creation.
Central venous catheterization was first performed in 1929 by a German doctor, Werner Frossmann, who inserted a ureteric catheter into his antecubital vein. He then went to the radiography department to guide it into his right ventricle under fluoroscopy. Not only was the experiment Werner Forssmann conducted on himself in 1929 of immense significance in paving the way for a monumental leap forward in cardiovascular care, but it was also an outstanding act of selfless courage. Now recognized as a key figure in the development of cardiac catheterization, for which he was awarded the 1956 Nobel Prize, Forssmann’s role risked his personal well-being in the process [11]. Later in 1961, Shaldon et al. [12] described the first approach of its kind by cannulating the femoral vein for dialysis access.
Central venous catheters (CVCs), initially designed as temporary solutions for vascular access, became increasingly common in the 1980s and 1990s, particularly in late-presenting or elderly patients. Their ease of placement and immediate usability contributed to their widespread use, despite their association with high rates of bacteremia, central venous stenosis, and mortality. The challenge of CVC overuse remains a central issue in vascular access management, especially in regions with limited access to surgical expertise or predialysis planning.
Next in line is the development of interventional radiology from the 1990s onwards. The integration of interventional radiology transformed vascular access maintenance. Techniques such as angioplasty, thrombectomy, and stent placement improved salvage rates and extended access lifespan. Simultaneously, routine access surveillance protocols using ultrasound or dynamic venous pressure monitoring were introduced to detect dysfunction early and guide timely interventions. Fig. 1 shows the timeline of events.
Each milestone addressed the limitations of its predecessor: the shunt enabled chronic dialysis but prompted the need for safer internalized access; the AVF provided durable, infection-resistant access that remains the gold standard; and grafts and catheters expanded options for patients with complex anatomy or urgent dialysis needs. Interventional radiology further reshaped practice by transforming access maintenance with angioplasty, thrombectomy, and surveillance strategies that prolong access life. These cumulative innovations underpin today’s multimodal approach, where AVFs, AVGs, and CVCs (discussed in the next section) are selected based on individualized patient characteristics, supported by sophisticated diagnostics, surgical expertise, and evidence-based guidelines.
Current modalities and clinical practice
Despite advances in dialysis technology, vascular access remains a key determinant of hemodialysis outcomes. Today, three primary types of vascular access are used: native AVFs, AVGs, and CVCs. Each has distinct indications, advantages, and limitations. The choice of optimal vascular access for an individual patient and determining the timing of access creation are dependent on a multitude of factors that can vary widely with each patient, including demographics, comorbidities, anatomy, and personal preferences [13].
AVFs remain the preferred vascular access for chronic hemodialysis, as endorsed by international guidelines including KDOQI [8]. Recent efforts focus on improving AVF outcomes through better vessel selection, ultrasound cannulation, and early detection of maturation failure.
AVGs involve subcutaneous placement of synthetic material (typically ePTFE) between an artery and a vein. They are commonly used when native vessels are not suitable, especially in elderly, obese, or diabetic patients with small or sclerotic veins.
CVCs are most commonly used for immediate vascular access, especially in patients who need dialysis emergently. The internal jugular vein is the preferred site due to its lower risk of stenosis and complications compared to other sites [14].
Controversies and limitations across vascular access types
Selection of vascular access for hemodialysis—AVF, AVG, or CVC—remains controversial due to trade-offs in maturation, complication rates, patient suitability, and long-term outcomes.
AVFs are traditionally favored for their superior long-term patency and lower infection rates, but they are limited by high rates of primary failure and delayed usability; more than 40% require additional procedures before successful use, and many never mature adequately, especially in older patients or those with poor vasculature [15–19]. This delays transition from CVCs, which exposes patients to higher infection and mortality risk during the waiting period [15,17,18]. Furthermore, intent-to-treat analyses show that the secondary survival advantage of AVFs over AVGs is diminished when accounting for primary failures and interventions required for maturation [15,18].
AVGs offer faster usability (typically 3–6 weeks post-placement) and more predictable outcomes in patients with unsuitable vessels for AVF creation, but they are associated with higher rates of infection and thrombosis and require more frequent interventions to maintain patency [16,18,19]. The cost of access management may be higher for AVFs than AVGs in patients who start dialysis with a CVC, challenging the assumption that AVFs are always the most cost-effective option [15].
CVCs provide immediate access and are often used at dialysis initiation, especially in patients without prior nephrology care or those requiring urgent therapy [17–19]. However, CVCs are associated with the highest risks of infection, hospitalization, and mortality, as well as central vein stenosis and thrombosis [17–19]. Despite these risks, a large proportion of patients in the United States initiate hemodialysis with a CVC, reflecting systemic barriers to timely AV access creation [17].
Additional controversies include the optimal site for AVF creation (forearm vs. upper arm), with recent data supporting superior maturation rates for upper arm AVFs, contrary to older guideline preferences [15]. Cannulation technique also influences infection risk; buttonhole cannulation is associated with higher rates of access-related bloodstream infection compared to rope ladder cannulation [16].
Patient-centered limitations include anatomical suitability, comorbidities, life expectancy, and preferences. Prior placement of peripherally inserted central catheters can compromise future AVF success, underscoring the importance of vessel preservation in patients with advanced CKD. For some patients, especially those with limited life expectancy or who do not wish to pursue long-term dialysis, the risks and burdens of AV access creation may outweigh potential benefits.
Fig. 2 summarizes all three access advantages and limitations for a comparative view.
Geographical differences in vascular access practices
Vascular access practices for hemodialysis exhibit substantial global and regional variability, driven by differences in healthcare infrastructure, workforce availability, funding mechanisms, patient demographics, and predialysis care pathways.
The medical literature demonstrates that high-income regions such as Western Europe and North and East Asia report higher rates of AVF or AVG use at dialysis initiation, with more than 50% of patients starting with these permanent accesses. In contrast, North America and the Caribbean have the highest rates of tunneled catheter use at initiation, while low-income countries—particularly in Africa and Latin America—rely predominantly on temporary catheters, with over 75% of patients initiating hemodialysis via this modality in many settings [20,21]. Understanding these geographic disparities is essential for global benchmarking and improving vascular access outcomes worldwide.
There are socioeconomic barriers in establishing vascular access that need to be considered when establishing a vascular access programme. Socioeconomic barriers are multifactorial and include disparities in insurance coverage, access to timely nephrology care, and health system infrastructure. Lack of insurance or underinsurance delays referral for permanent vascular access placement, often resulting in late-stage presentation and initiation of hemodialysis with a CVC rather than an AVF or graft, which is associated with worse outcomes [22,23]. Marginalized populations, including racial and ethnic minorities, experience lower rates of incident AVF/AVG use, driven by reduced access to predialysis nephrology care and kidney disease education, as well as language barriers and other social determinants of health [22,23]. These disparities persist even within similar insurance status groups, indicating that cultural, behavioral, and systemic factors play a significant role [22].
Training barriers are also prominent. The successful creation and maintenance of vascular access require coordinated multidisciplinary care, including skilled nephrologists, surgeons, and dialysis staff. Inadequate training facilities, lack of dedicated educators, and limited experience among care teams in vascular access techniques—especially for home hemodialysis—impede optimal access outcomes [24,25]. Patient and provider inexperience with cannulation techniques, such as rope ladder and buttonhole methods, increases the risk of complications and infections, further discouraging AVF use [24]. Additionally, insufficient predialysis education and lack of interdisciplinary care models contribute to unplanned dialysis starts with catheters and suboptimal vascular access selection [25].
Social factors, such as fear of pain, anxiety about self-cannulation, and concerns about the physical appearance of vascular access, influence patient preferences and may lead to higher rates of catheter use, particularly in dialysis centers where catheter use is culturally normalized [26]. The dialysis unit’s culture and the presence or absence of a vascular access team-based approach can significantly affect both patient education and outcomes [24,26].
Developed countries: high arteriovenous fistula utilization, declining trends
In many high-income countries, especially in Europe and parts of Asia, AVFs have traditionally been the predominant form of access. Countries such as Japan, the Netherlands, and Germany report AVF use rates exceeding 70% to 80%, reflecting early nephrology referral, routine vascular mapping, and strong surgical programs. Japan, in particular, has maintained one of the highest AVF usage rates globally, attributed to strict catheter-avoidance protocols and dedicated access care teams. Data from large international cohorts, including the Dialysis Outcomes and Practice Patterns Study (DOPPS), confirm that Japan consistently achieves AVF use rates above 85%, while many European countries, including Germany and the Netherlands, report rates in the 60%–80% range, with some centers exceeding these benchmarks [27,28].
In contrast, countries with lower AVF use rates, such as the United States, often face challenges including late nephrology referral, delayed surgical evaluation, and less routine use of vascular mapping, resulting in higher rates of catheter and graft use at dialysis initiation [29,30]. According to United States Renal Data System data, there has been a shift toward increased use of AVGs and persistent catheter dependency, particularly in older adults and patients initiating dialysis urgently [31,32]. This reflects changing demographics, growing emphasis on individualized access planning, and recognition of high AVF maturation failure in certain populations.
Emerging economies: high catheter dependency and access challenges
In low- and middle-income countries, CVCs remain disproportionately used as the primary vascular access, particularly at dialysis initiation [21,33]. Reports from South Asia, sub-Saharan Africa, and parts of the Middle East show catheter rates exceeding 50% to 60%, often due to: late nephrology referral, lack of access to vascular surgeons, cost barriers to AVF creation, limited awareness or patient education, and inadequate infrastructure for predialysis planning. Additionally, recurrent access infections, short catheter dwell times, and limited salvage procedures compound the problem in these regions. Reducing the use of CVCs in low-income countries requires a multifaceted approach that packages dialysis and vascular access planning together, with emphasis on early intervention, patient-centered care, and context-appropriate technology.
Regional programs and policy impact on access utilization
Countries that have implemented national vascular access guidelines, mandatory vascular mapping prior to dialysis initiation, or incentive-based policies have seen better outcomes. For example, the United Kingdom’s NICE (National Institute for Health and Care Excellence) guidelines promote predialysis planning and early AVF formation [34]. In Australia and New Zealand [35], early referral pathways and multidisciplinary access clinics have helped maintain AVF prevalence around 60% to 70%. Saudi Arabia and Gulf countries are investing in structured dialysis programs but still face variability in access types across urban vs. rural centers.
Global initiatives and future directions
International collaborations such as the DOPPS have highlighted these access disparities and informed quality improvement initiatives. Moving forward, efforts to improve early CKD detection and referral, expand training for access creation and maintenance, develop low-cost vascular access technologies, and implement registry-based monitoring for access outcomes are critical to addressing the global inequities in vascular access care.
Future directions and innovations in vascular access for hemodialysis
While significant strides have been made in vascular access development over the past decades, challenges such as high failure rates, infections, and complications persist. To address these gaps, the nephrology and vascular communities are actively pursuing innovations that aim to improve outcomes, enhance access longevity, and individualize care for hemodialysis patients. Several promising trends are emerging in the fields of device development, imaging, surgical technique, and personalized medicine.
Endovascular arteriovenous fistula creation
One of the most significant recent innovations is percutaneous endovascular AVF creation, which offers a minimally invasive alternative to traditional surgical methods [36]. Systems such as Ellipsys (Medtronic) and WavelinQ (Becton, Dickinson and Company) use ultrasound or fluoroscopic guidance to create a fistula between the deep communicating vein and radial or ulnar artery.
Advantages include reduced surgical trauma and scarring, faster recovery times, and comparable maturation rates to surgical AVFs in selected patients. This technique is especially beneficial in patients with difficult anatomy or high surgical risk and is gaining adoption in centers with appropriate imaging and interventional expertise. The approach can be particularly helpful for elderly patients with less-than-optimal circumstances for the creation of a traditional radial-cephalic fistula. As the population ages, this approach of AVF creation gains more importance. A major benefit of this approach is its minimally invasive nature and avoidance of general anesthesia altogether. As such, the approach helps minimize morbidity and mortality in the elderly patients with CKD.
Endovascular AVF creation is associated with substantially higher upfront procedural costs compared to surgical AVF creation. The cost-effectiveness of endovascular AVF is highly sensitive to procedural pricing, maturation rates, and quality-of-life gains, and surgical AVF remains the more cost-effective strategy in most modeled scenarios. Table 1 [37–41] presents a head-to-head comparison between surgical AVF and endovascular AVF based on published literature.
Bioengineered and tissue-engineered grafts
Bioengineered grafts for hemodialysis access are an emerging class of vascular conduits designed to address the limitations of conventional synthetic materials such as ePTFE, which are prone to infection, intimal hyperplasia, and thrombosis. These grafts are typically constructed using tissue engineering approaches that combine biological and synthetic components, or utilize decellularized biological scaffolds, with the goal of improving patency, biocompatibility, and host integration [42].
The most clinically advanced bioengineered grafts are human acellular vessels (HAVs), which are manufactured by culturing human vascular cells on a biodegradable scaffold, followed by decellularization to produce an off-the-shelf, non-immunogenic conduit. Phase 2 clinical trials have demonstrated that HAVs can be safely implanted for dialysis access, with patency rates at 6 and 12 months comparable to ePTFE, low infection rates, and evidence of host cell repopulation and remodeling without structural degeneration or aneurysm formation [43]. These grafts do not require patient-specific cell harvesting and can be used in patients who are not candidates for autogenous fistula creation.
Fig. 3 shows how bioengineered grafts are prepared.
Potential benefits are enhanced biocompatibility, resistance to infection, and improved long-term patency. Although still under investigation in clinical trials, these grafts may represent the future of AVGs, especially for patients unsuitable for AVFs.
Wearable and remote monitoring technologies
The rise of digital health is enabling real-time monitoring of vascular access. Wearable sensors and connected devices are being developed to continuously monitor access flow rates, thrill and vibration patterns, cannulation sites, and needling angles. Remote monitoring platforms can alert clinicians to early signs of dysfunction, allowing preemptive interventions. Integration with electronic health records and dialysis machines could lead to smarter, data-driven access care [44,45].
Sensor-based detection of vascular access for hemodialysis encompasses a range of technologies designed to monitor patency, detect complications, and guide cannulation. These sensors function by exploiting physical, optical, and electrical properties associated with blood flow, vessel wall motion, and the presence of blood or thrombus.
Thermal sensors, such as those described in recent studies, utilize thermal anemometry to noninvasively assess blood flow within vascular access sites. These soft, wearable devices detect changes in heat dissipation caused by blood flow, allowing for continuous monitoring of flow dynamics and early detection of access dysfunction, including stenosis or thrombosis. The sensitivity of these sensors has been validated in both preclinical and clinical settings, and wireless adaptations are under development for at-home monitoring [46].
Implantable pressure sensors integrated into AVGs represent another approach. These battery-free, wireless devices employ capacitive pressure sensing and inductive coupling to detect real-time changes in intragraft pressure profiles. Variations in pressure waveforms can indicate the presence of arterial or venous stenosis, and the system can transmit data externally for remote monitoring. The flexible design maintains graft functionality and resilience under physiological conditions [47].
Optical sensors, including near-infrared (NIR) and NIR-II imaging probes, are used for both preoperative mapping and postoperative surveillance. These probes enable visualization of vascular anatomy, assessment of access maturation, and detection of thrombus or flow abnormalities by capturing real-time hemodynamic and structural information. The use of individualized probes with specific excretion pathways allows for repeated imaging in patients with renal impairment [48,49].
Non-contact optical imaging systems have also been developed to analyze thrill waveforms over AVFs. By capturing subtle surface vibrations and converting them into quantitative data, these systems can distinguish between normal and stenotic access based on waveform characteristics, providing an alternative to traditional palpation and auscultation [50]. Additional sensor modalities include hemoglobin-specific optical sensors for bleeding detection at access sites, which trigger alarms upon detecting blood via reflected light signatures, and concentric ring electrical sensors for real-time detection of blood leakage, such as from needle dislodgement, with high sensitivity and specificity [51,52].
Collectively, these sensor technologies enable early detection of access dysfunction, improve safety by automating complication detection, and facilitate remote or continuous monitoring, thereby supporting timely intervention and optimizing hemodialysis outcomes [46–52].
Fig. 4 shows the overview of how sensors work and display findings.
Precision vascular access planning
There is growing interest in applying precision-medicine principles to vascular access by tailoring access choice and management to individual risk profiles, including vascular anatomy (using high-resolution imaging), comorbidities (e.g., diabetes, heart failure, peripheral vascular disease), life expectancy, and dialysis trajectory. Starting early in a patient with CKD is still an important step toward precision vascular access planning.
Tools such as vascular access risk prediction models, artificial intelligence for image analysis, and decision-support algorithms may help optimize access selection and minimize complications.
Antimicrobial and drug-eluting access devices
To combat infection and thrombosis, research is focusing on antimicrobial-coated catheters, heparin-bonded grafts, and drug-eluting materials.
Vascular catheters are critical tools in modern healthcare yet present substantial risks of serious bloodstream infections that exact significant health and economic burdens. Drug-eluting antimicrobial vascular catheters have become important tools in preventing catheter-related bloodstream infections and their importance is expected to increase as significant initiatives are expanded to eliminate and make the occurrence of these infections unacceptable [53].
Policy and global strategy innovations
Beyond technology, health policy innovation plays a critical role in improving access outcomes. Fig. 5 displays the pathway for improving AVF prevalence worldwide.
Initiatives include:
• Early CKD screening programs [54]
• Structured predialysis education clinics
• Reimbursement models that incentivize AVF creation [55]. The medical literature strongly supports the integration of dialysis initiation planning with vascular access management to reduce the use of CVCs, which are associated with increased risks of infection and mortality in patients with ESKD. The concept of packaging dialysis and vascular access together is consistent with the current consensus that vascular access should be considered a critical component of the ESKD life-plan, requiring early and coordinated multidisciplinary involvement.
• Global registries to monitor access trends and outcomes [56]
Efforts by international organizations like DOPPS, the European Renal Association, and the International Society of Nephrology are promoting equitable access to vascular access care globally.
Conclusion
The evolution of vascular access in hemodialysis continues, with innovations aiming to make access creation safer, more effective, and more personalized. As new technologies emerge—from minimally invasive techniques and bioengineered grafts to digital monitoring and precision planning—the future of vascular access promises improved patient outcomes, reduced complications, and greater global equity in dialysis care. Multidisciplinary collaboration, patient-centered planning, and continuous research will be essential to realize these goals.
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