Vascular surgery was forever changed – and the field of dialysis access established – with the advent of the Scribner shunt at the University of Washington in 1960 [1]. This external, Teflon tube is attached to the arterial and venous circulation (in the forearm or ankle) and then joined together in the “U” configuration by connectors and a piece of heparinized Teflon, while the patient is not actively being dialyzed. Later in the same decade, Drs. Brescia, Cimino, and Appell conceptualized the first autogenous, or non-synthetic, dialysis access in the form of the connection of the cephalic vein to the radial artery (radiocephalic arteriovenous fistula) [2].

In 1969, just 2 years after the clinical implementation of the arteriovenous fistula (AVF), the first autologous graft was used for the creation of an arteriovenous access almost simultaneously in both Mexico and Australia [3, 4]. Flores Izquierdo and May described the use of the saphenous vein for the creation of a forearm loop arteriovenous graft (AVG). May et al. observed that there was a group of patients in which both the suitable artery and the vein were lacking for the creation of an AVF, and an interposed conduit was required to provide an area of blood flow and access for hemodialysis.

These seminal events led to much excitement in the field of access creation and hence the further development and use of other materials, such as expanded polytetrafluoroethylene (ePTFE) and Dacron (polyethylene terephthalate) [5, 6] (Fig. 18.1). In the 1970s the use of ePTFE was pioneered as a suitable vascular graft and was rapidly adopted as an alternative material for connecting arteries and veins in an array of configurations around the body [7]. This fundamental advance of using an interposed synthetic tube to provide blood flow superficially beneath the skin for hemodialysis access has been a mainstay of access for millions of patients and can often be a life-sustaining solution for those patients whose, for an array of reasons, creation of a native AVF is not possible.

The conception of prosthetic grafts revolutionized vascular access and gave rise to a number of new access sites that were previously unavailable when creation of an AVF was the sole option. However, this new type of vascular access presented a whole new set of challenges and complications, driving expenditures for dialysis access to another level. Today the health and social realities of ESRD are tremendous, with economic costs in the USA estimated at more than 2.9 billion dollars to maintain malfunction dialysis access [8]. While dialysis grafts have provided reliable access for millions of patients in need of hemodialysis, they are still far from ideal. Currently, regardless of the material used for an artificial AVG, their mean patency remains generally poor averaging between 9 and 15 months, and infection rates are greater than AVFs [9–13]. Further, enduring patency often requires multiple interventions including mechanical thrombectomy, thrombolysis, angioplasty, stent placement, and/or surgical revision. These interventions are fraught with recurrent failure, cost millions of healthcare dollars, and expose the patient to increased morbidity and mortality [8].

In patients lacking suitable vein for conduit, ePTFE is the most commonly used synthetic solution for creation of arteriovenous access. There are multiple modes of failure that plague prosthetic vascular access grafts including neointimal hyperplasia in the outflow vein, thrombosis, infection, graft ultrafiltration (weeping), steal syndrome, and traumatic degeneration of graft material [14]. Further, synthetic conduit has several biologic challenges. Specifically, because the conduit lacks the ability to form a stable endothelium, it appears to be more thrombogenic. Because it is impermeable to white blood cells, synthetic material is more prone to infection, which may lead to the need for surgical excision. Additionally, due to mechanisms that are incompletely understood, the body’s response to synthetic material can result in venous neointimal hyperplasia leading to venous outflow stenosis. Progressive outflow stenosis increases the pressure in the access and decreases the flow, which can increase the risk of graft cannulation bleeding and ultimately graft thrombosis. There are several proposed mechanisms by which venous outflow stenosis can occur in AV access models. Favored mechanisms cite inflammatory responses to synthetic material, as well as compliance mismatch between native vein and synthetic material resulting in hyperplasia at the transition zone between conduits [15]. Finally, synthetic conduit is prone to degradation over time due to “coring” caused by repeatedly accessing the graft with large bore needles for dialysis, resulting in the formation of pseudoaneurysms.

Although their initial use was met with much excitement, limitations of synthetic AVG such as infection and thrombosis were quickly recognized, leading to the development of biologic or bioengineered conduit, with several examples persisting to this date, including bovine carotid artery (Artegraft®, Artegraft, Inc., North Brunswick, NJ), bovine mesenteric vein (ProCol®, LeMaitre Vascular, Inc., Burlington, MA), and cryopreserved (human) femoral or saphenous vein (CryoVein®, CryoLife, Inc., Kennesaw, GA), among others [16–22]. However, biologic grafts are typically more expensive than standard synthetic ePTFE choices, and early iterations of such grafts were fraught with more troublesome complications such as rapid aneurysmal degradation and did not completely mitigate infectious complications as suspected [23]. Additionally, many patients utilize hemodialysis as a “bridge” to kidney transplantation, subsequently leading to concerns over induction of the immune response and overall antigenic properties of various graft materials.

However, as one can surmise, there have been modifications to previously developed graft materials and the introduction of new synthetic materials, such as polyurethane [24]. Modifications and introduction of new materials have, in theory, provided for earlier cannulation and less graft complications (i.e., ultrafiltration syndrome or “graft weep”) than older materials. New graft construction techniques, such as tissue-engineered vessels and three-dimensional (3D) printing, are unveiling an exciting new frontier for further development of easily handled, personalized, injury proof, and readily available HD access grafts, both biologic and synthetic.