Figure 2.

ECM remodelling after AVF creation. The native vein (left panel) requires rebuilding its vascular scaffold to facilitate AVF maturation. The venous outflow tract undergoes ECM degradation (middle panel) and rebuilding of the ECM framework through ECM deposition (right panel). After AVF creation, the intimal layer and glycocalyx are damaged, and increased wall shear stress induces outward remodelling. Degradation of the ECM is facilitated by increased MMP (matrix metalloprotease) production, degrading collagen and elastin. Proliferating VSMCs ensure outward remodelling and wall thickening. Eventually, VSMCs migrate into the intima, where they proliferate and form intimal hyperplasia. During ECM deposition, collagen is produced by VSMCs and myofibroblasts. LOX (lysyl oxidase) cross-links elastin and collagen into their respective fibre formations.