Bioengineered Vascular Grafts for Hemodialysis Access: Design Requirements, Clinical Evidence, and Translational Barriers.

Autogenous arteriovenous fistulas (AVFs) remain the preferred hemodialysis access when suitable vessels and sufficient maturation time are available, but high nonmaturation rates, catheter dependence, and increasing multimorbidity in end-stage kidney disease (ESKD) have intensified the need for reliable alternative conduits. Conventional expanded polytetrafluoroethylene (ePTFE) grafts provide an immediately available surgical option, yet their chemically inert surfaces are not intrinsically blood-compatible and remain susceptible to thrombosis, infection, compliance mismatch, and venous neointimal hyperplasia. This critical review evaluates bioengineered vascular grafts as candidate solutions for hemodialysis access, emphasizing how material design, tissue-engineered scaffolds, and localized therapeutic delivery must be matched to dialysis-specific requirements, including puncture sealing, suture retention, infection resistance, endothelialization, and high-flow durability. Early clinical experience with endogenous tissue restoration grafts, human acellular vessels, and scaffold-free autologous tissue-engineered grafts provides encouraging signals, but current evidence remains limited by small cohorts, single-arm designs, incomplete comparative data, and uncertain long-term performance under repeated cannulation. We also examine major translational barriers, including the "uremic mismatch" between healthy animal models and the inflammatory, calcified, hypercoagulable, and immunologically impaired ESKD milieu. Finally, immunomodulatory scaffolds, 4D-printed structures, and biosensing graft concepts are discussed as experimental research directions rather than established clinical solutions. A patient-centered, ESKD Life-Plan-informed strategy may ultimately align graft selection with vessel quality, life expectancy, dialysis trajectory, and acceptable intervention burden.