• Vascular access being unphysiological, access failure is common but a matter of critical priority:

o Failure to mature (FTM)

o Failure of mature arteriovenous fistula (AVF).

• Mechanism of AVF failure – Inflammatory stimuli, genetic predisposition, hemodynamic stressors and vascular injury.
• Causes of FTM – Accessory veins, outflow obstruction, poor inflow-arterial atherosclerosis/stenosis.
• Failure of functioning AVF – Outflow/inflow tract stenosis venous-swing-point, juxta-anastomotic, brachial-basilic angle of transposition, cephalic arch, central vein stenosis and thrombosis arterial stenosis.
• Management – Angioplasties, stenting of stenotic lesions:

o Reanastomosis, endovascular thrombolysis. Open thrombectomy.

• Strategies for prevention: Screening for and avoiding predisposing factors, regular evaluation – hand elevation, augmentation tests, Pick early dysfunction for angiography and early interventions, Systemic medical therapies/local therapeutic intervention.
• New – Far-infrared therapy, preoperative forearm exercise and fistula assist device.
• Last ditch procedure – HERO graft and surface.
• Future – Tissue engineered vascular grafts, endo-AVF and the dynamic AVF.