Endovascular Interventions

**Percutaneous transluminal angioplasty (PTA):** Balloon angioplasty is the first-line endovascular treatment for most access stenoses, whether in native arteriovenous fistulas (AVF) or prosthetic grafts. The procedure involves advancing a balloon catheter across the stenotic segment and inflating it to restore luminal diameter. Technical success rates exceed 90%, though restenosis is common, particularly at the venous anastomosis of grafts. Drug-coated balloons eluting paclitaxel have demonstrated improved target-lesion primary patency in arteriovenous fistulasAVF compared with plain balloon angioplasty in randomized controlled trials, though ongoing safety surveillance continues. [@lok2020, @esvs2018-access, @lookstein2020, @kitrou2019]

**Thrombectomy:** Acute access thrombosis can often be salvaged through pharmacomechanical or mechanical thrombectomy techniques. These include catheter-directed thrombolysis, rheolytic thrombectomy, and mechanical aspiration devices. Thrombectomy is typically combined with angioplasty to address the underlying stenosis responsible for thrombosis, as failure to correct the causative lesion results in early rethrombosis. [@lok2020]

**Stent-grafts:** Covered stents (stent-grafts) are indicated for specific complications including recurrent stenosis refractory to angioplasty, venous rupture during angioplasty, and selected pseudoaneurysms. Randomized data demonstrate superior patency of stent-grafts compared with angioplasty alone for recurrent graft-vein anastomotic stenosis in arteriovenous grafts.grafts (AVG). Bare metal or covered stents may also be used for central venous stenosis (CVS) with elastic recoil after balloon angioplasty.angioplasty [@haskal2010, @lok2020, @esvs2018-access]@esvs2018-access]. Recent registry data support the use of stent placement following percutaneous recanalization for superior vena cava (SVC) stenosis in hemodialysis patients to maintain vessel patency [@zhao2024].