Biomechanics of Arteriovenous Fistula: An Overview of Hemodynamic and Remodeling Mechanisms

Arteriovenous fistulas (AVFs) are widely accepted as the gold standard for vascular access in chronic hemodialysis patients due to their superior long-term patency and low complication rates. However, up to half of all created AVFs fail to mature adequately, and many develop late complications such as stenosis, thrombosis, or aneurysmal degeneration. This review provides an overview of the AVF development process, focusing on the biomechanical forces that drive vascular remodeling and contribute to maturation and pathological changes. We summarize the role of endothelial mechanotransduction and insights from recent studies that reveal how wall shear stress (WSS) patterns and oscillatory flow relate to the genesis of neointimal hyperplasia and later stenosis. Understanding these mechanobiological processes has led to novel surgical techniques, anastomosis design optimization, and better cannulation strategies. Although the knowledge of hemodynamic-biological interactions remain limited, further research can offer directions for better AVF performance.