A Novel Single-Needle Distal Return Strategy Achieves Sustained Dialysis Efficacy and Eliminates Reinterventions in High-Risk Arteriovenous Fistulas

Abstract

Rationale & Objective

Patients with arteriovenous fistulas (AVFs) facing recurrent interventions endure high procedural burdens and costs. We evaluated a novel single-needle distal return (SNDR) technique in refractory AVF cases to assess its impact on dialysis adequacy, reintervention rates, and economic outcomes.

Study Design

Single-center retrospective self-controlled study.

Setting & Participants

Twenty-five maintenance hemodialysis patients at a tertiary Chinese center (2021-2025) with AVF failure because of complete outflow occlusion (n = 6), venous hypertension (n = 8), procedural fatigue (n = 5), or inadequate cannulation length (n = 6).

Findings

Over a median follow-up of 24 months, SNDR significantly improved dialysis adequacy (median single-pool Kt/V: 1.08 vs 1.46, P < 0.001) and ultrafiltration achievement ratio (72% vs 98%, P < 0.001). The annualized reintervention rate decreased by 90% (3.7 to 0.36 events/year, P < 0.001), access-related costs fell by 88% (¥135,000 to ¥16,000/year, P < 0.001), and temporary catheter use was eliminated in 88% of patients. Safety outcomes improved: dialysis machine alarms decreased from 28 to 3 per 100 sessions (P < 0.001) and hematoma rates from 8.0% to 1.5% of sessions (P < 0.001). Venous pressure remained within safe ranges (124 vs 118 mm Hg, P = 0.15).

Limitations

Single-center retrospective design and modest sample size limit generalizability.

Conclusions

The SNDR technique not only sustained but improved dialysis efficacy while substantially reducing reinterventions, costs, and complications in complex AVF failure. This approach represents a transformative salvage strategy that substantially reduces costs before resorting to catheter-dependent options.

Plain-Language Summary

For hemodialysis patients whose lifesaving arm vessel access has become severely damaged and blocked, repeated repair surgeries are painful, costly, and often temporary. We tested a new needle placement method to “rescue” these failing access sites. Instead of using 2 needles in the damaged vessel, we used only one needle there to draw blood, and a second needle in a vein in the foot or lower leg to return the cleansed blood. In patients who had run out of standard options, this approach successfully maintained effective dialysis, drastically reduced the need for more surgeries, and lowered costs. This technique offers a valuable last-resort alternative to using a dialysis catheter, which carries higher risks.

The advent of the Brescia–Cimino arteriovenous fistula (AVF) in 1966 marked a revolutionary milestone in hemodialysis access, establishing subcutaneous arteriovenous anastomosis as the gold standard for durable vascular access.¹ By arterializing superficial veins, this technique enabled repetitive dual-needle cannulation (arterial inflow/venous return) while minimizing infection risks compared with earlier Quinton–Scribner shunts.² Over 6 decades, AVFs have become the cornerstone of global hemodialysis, with contemporary utilization rates ranging from 68% to 91%.^3,4

Paradoxically, the longevity afforded by AVFs has engendered a new crisis: cumulative trauma from thrice-weekly dual-needle punctures over years of use. In the United States, approximately 50% of mature AVFs develop recurrent stenosis or thrombosis within 3 years, necessitating repeated percutaneous transluminal angioplasty (PTA).⁵ Despite its widespread adoption, PTA offers only transient relief, with more than half of AVFs requiring repeat interventions within 6 months.5, 6, 7 This cycle of interventions imposes substantial economic burdens, as evidenced by Korean data showing annual vascular access-related costs exceeding $15,000 per patient, alongside profound psychological distress from recurrent procedures.⁸ This unsustainable cycle may stem from two plausible mechanisms: repeated PTA procedures likely induce mechanical trauma that exacerbates intimal hyperplasia, whereas conventional dual-needle cannulation generates turbulent flow patterns during dialysis, potentially exposing the venous outflow tract to pathologic shear stresses that accelerate vascular remodeling.9, 10, 11, 12

Efforts to mitigate these challenges have focused on cannulation strategy optimization.¹³ Traditional single-needle techniques, whereas reducing puncture-related vascular damage and subsequent complications, were historically constrained by suboptimal dialysis efficiency.^14,15 Recent advancements have revitalized interest in this approach.^15,16 China’s 2021 Blood Purification Standard Operating Procedures (National Health Commission of China, Chinese Edition, 2021) explicitly advocates single-needle cannulation with distal venous return for immature fistulas—a protocol mirroring our SNDR technique’s core principle of minimizing anastomotic segment trauma. Although long-term outcome data remain limited in China, robust evidence from Japan demonstrates feasibility: superficialized brachial artery single-needle access combined with distal venous return achieves 78% 5-year patency rates, proving peripheral veins tolerate prolonged cannulation when managed with rotation protocols.17, 18, 19, 20

Building on these foundations, we developed a novel single-needle distal return (SNDR) strategy, characterized by arterial cannulation at the juxta-anastomotic segment paired with venous return via superficial veins in the lower extremities. This approach offers a multifaceted solution: it minimizes cannulation-induced trauma to the fistula by reducing puncture sites, eliminates recirculation to enhance dialysis efficiency, and crucially, preserves future vascular capital by utilizing distal veins typically unsuitable for conventional access creation. By circumventing pathological outflow tracts and avoiding repetitive interventions, the SNDR technique directly addresses the dual burdens of access attrition and procedural exhaustion.

Materials and Methods

Study design and participants

This single-center, retrospective, self-controlled study was conducted at the Hemodialysis Center of Anhui Medical University Suzhou Hospital, a tertiary teaching hospital managing approximately 400 maintenance dialysis patients. The study protocol was reviewed and approved by the institutional review board of Our Hospital (IRB Nos. KY-YJ-2025-056 and YKSDYRMYYEC2024-KT-HS-061-01), which waived the requirement for informed consent because of the retrospective nature of the analysis using de-identified data.

We screened all adult patients undergoing maintenance hemodialysis between January 2021 and June 2025. Eligibility required a diagnosis of chronic AVF failure meeting at least 1 of the following criteria: complete or near-complete venous outflow occlusion confirmed by physical examination and ultrasonography; venous hypertension manifesting as dialysis-induced limb edema that resolved post-treatment; patient refusal of further interventions because of procedural fatigue after two or more failed PTA procedures; or inadequate cannulation length, defined as less than 3 cm of viable venous segment as measured by ultrasound. Patients with active infection, decompensated heart failure, or severe peripheral venous disease were excluded. The SNDR procedure was considered only for patients whose upper extremity venous options were deemed exhausted after evaluation. Those with patent, usable ipsilateral brachial, basilic, or cervical superficial veins for return were managed accordingly and not included in this cohort. Ultimately, 25 patients were enrolled and constituted the study cohort.

Intervention: Single-needle distal return technique

All hemodialysis sessions were performed thrice weekly for 4 hours using B. Braun Dialog+ dialysis machines equipped with the Adimea UV-Kt/V monitoring module, following China’s 2021 Blood Purification Standard Operating Procedures.²¹ Anticoagulation was achieved through standardized low-molecular-weight heparin (LMWH) protocols (60-80 IU/kg). The novel SNDR technique was implemented as follows. For arterial inflow, a 17-gauge fistula needle was inserted into the patent juxta-anastomotic segment of the AVF; Cannulation was performed primarily via tactile guidance by experienced nurses, with ultrasound assistance reserved for non-palpable segments. For venous return, dialyzed blood was redirected through a 17-gauge needle placed in a superficial vein of the lower extremities, preferentially targeting the dorsalis pedis arch or tributaries of the great saphenous vein. No preemptive surgical or endovascular procedure was performed to modify the lower extremity venous return sites. A strict bilateral rotation protocol was enforced, alternating between the left and right limbs for consecutive sessions to ensure each puncture site had a minimum of 72 hours for recovery. To enhance venous preservation and cannulation success, patients applied warm compresses (40 °C for 15 minutes) to target areas pre-dialysis and received 40-minute far-infrared therapy on noncannulated limbs during sessions. Following dialysis completion, arterial needle removal required manual pressure application for 10-30 minutes until complete hemostasis, whereas venous needle removal necessitated 5-10 minutes of compression because of the low-pressure characteristics of superficial venous return sites. A comprehensive visual overview of the SNDR technique, including cannulation sites and long-term venous integrity across 4 representative patient scenarios, is provided in Figure 1.

Figure 1.

Technical overview and clinical application of SNDR technique in four representative patients with complex AVF failure. (A) A case of a 46-year-old woman with a chronically occluded left brachiocephalic AVF. (A1) The occluded fistula exhibits a tense, pulsatile segment near the anastomosis, with absent thrill on physical examination. A approximately 3-cm patent puncturable segment is preserved. (A2) Cannulation of the arterial needle into the juxta-anastomotic segment. (A3) View of the dorsal foot veins after 4.5 years of intermittent cannulation, demonstrating preserved integrity and minimal morphological changes, which facilitates repeated puncture. (A4) Cannulation of the venous return needle into a superficial dorsal foot vein. (A5) Overview of the established SNDR circuit during hemodialysis, illustrating the complete pathway from the arterial needle in the upper limb to the venous return needle in the lower limb. (B) A 68-year-old woman with venous hypertension presenting as dialysis-induced limb edema that resolved post-treatment. The SNDR technique has been successfully employed for 2.8 years. (C) A 62-year-old female with procedural fatigue after undergoing 7 percutaneous transluminal angioplasties (PTAs) within 1 year before SNDR initiation. He has been managed with SNDR for 1.2 years. (D) A 78-year-old woman with an inadequate cannulation length (<3 cm) following multiple AVF surgeries and PTAs. She has been maintained on SNDR for 3.8 years.

Data collection and outcome measures

Data were retrospectively extracted from integrated electronic medical records, digitized dialysis logs generated by the B. Braun Dialog+ system and “Diassist” (a localized hemodialysis management software), and hospital billing databases. Collected variables included patient demographics, dialysis vintage, primary etiology of end-stage renal disease, comorbid conditions, and the primary indication for SNDR.

The pre- and post-intervention observation periods were defined individually for each patient. The pre-SNDR period spanned from the first recorded PTA event (excluded as the index procedure) to the initiation of SNDR. The post-SNDR period extended from the first SNDR treatment to the last follow-up or June 2025. Outcome measures were annualized to account for varying observation times.

Primary outcomes were dialysis adequacy and reintervention burden. Dialysis adequacy was assessed by the single-pool Kt/V and the urea reduction ratio (URR). The Kt/V values were automatically calculated after each session using the machine-embedded Adimea module, whereas URR was determined using a monthly calculation based on pre- and post-dialysis blood urea nitrogen (BUN) levels measured from routine laboratory tests. The reintervention rate was calculated as the total number of PTA or thrombectomy procedures divided by the total observation time in years for each period.

Secondary outcomes encompassed access-related costs, temporary catheter use, and safety parameters. Annualized costs included all expenditures for procedures, hospitalizations, and catheter placements related to vascular access dysfunction. Safety outcomes included the rate of dialysis machine alarms (per 100 sessions), the proportion of sessions complicated by needle-related hematomas requiring intervention, and the mean intradialytic venous pressure.

Statistical analysis

Continuous variables were assessed for normality using the Shapiro–Wilk test. Non-normally distributed data were presented as median and interquartile range (IQR), while categorical variables were summarized as frequencies and percentages. Given the self-controlled design, pre- and post-SNDR comparisons for continuous outcomes were performed using paired samples t test for normally distributed parameters (Kt/V, URR) and the Wilcoxon signed-rank test for non-normally distributed parameters (reintervention rate, costs, alarm rates, hematoma rates). The McNemar test was used for binary categorical outcomes (temporary catheter use). All analyses were conducted using SPSS software version 27.0 (IBM Corp), and a two-tailed P value of less than 0.05 was considered statistically significant.

Results

Baseline characteristics of the study cohort

The study cohort consisted of 25 patients with a median age of 58 years (interquartile range [IQR], 49-67) and a median dialysis vintage of 5.8 years (IQR, 3.2-9.5). The majority of patients were male (64%), and hypertensive nephropathy was the leading cause of end-stage renal disease (60%). All patients presented with complex AVF failure, with the primary indications for salvage therapy being venous hypertension (32%), complete or near-complete outflow occlusion (24%), inadequate cannulation length (24%), and procedural fatigue or refusal of further interventions (20%). Comorbid conditions, including hypertension (88%), chronic heart failure (36%), and coronary artery disease (32%), were highly prevalent. The detailed baseline characteristics of the overall cohort and stratified by primary indication are presented in Table 1.

Table 1.

Baseline Characteristics of the Study Cohort by Primary Indication for SNDR^a

Characteristic	Total (N = 25)	Complete/Near-Complete Outflow Occlusion (n = 6)	Venous Hypertension (n = 8)	Intervention Fatigue/ Refusal (n = 5)	Inadequate Cannulation Length (n = 6)	P Value
Demographics
Age, y	58 (49-67)	61 (52-70)	55 (48-65)	62 (55-69)	57 (46-63)	0.45
Male sex	16 (64.0)	4 (66.7)	6 (75.0)	3 (60.0)	3 (50.0)	0.82
Clinical History
Dialysis vintage, y	5.8 (3.2-9.5)	7.5 (4.8-11.3)	4.5 (2.5-7.8)	6.0 (3.5-10.5)	5.5 (2.8-8.3)	0.38
Primary etiology of ESRD
Hypertensive nephropathy	15 (60.0)	4 (66.7)	5 (62.5)	3 (60.0)	3 (50.0)	0.96
Diabetic nephropathy	4 (16.0)	1 (16.7)	1 (12.5)	1 (20.0)	1 (16.7)	>0.99
Chronic glomerulonephritis	6 (24.0)	1 (16.7)	2 (25.0)	1 (20.0)	2 (33.3)	0.91
Comorbid conditions
Hypertension	22 (88.0)	6 (100)	7 (87.5)	4 (80.0)	5 (83.3)	0.79
Chronic heart failure	9 (36.0)	3 (50.0)	2 (25.0)	2 (40.0)	2 (33.3)	0.81
Coronary artery disease	8 (32.0)	2 (33.3)	3 (37.5)	1 (20.0)	2 (33.3)	0.96
Cerebrovascular disease	6 (24.0)	2 (33.3)	1 (12.5)	1 (20.0)	2 (33.3)	0.80

Abbreviations: ESRD, end-stage renal disease; SNDR, single-needle distal return.

^aData are presented as median (interquartile range) for continuous variables and n (%) for categorical variables. P values represent differences across the four indication groups and were calculated using the Kruskal–Wallis test for continuous variables and Fisher exact test for categorical variables.

Primary Outcomes: Dialysis Adequacy and Reintervention Burden

The median (IQR) observation period was 22.5 (12.0-35.0) months for the pre-SNDR phase and 24.0 (18.0-36.0) months for the post-SNDR phase. The comparative results for primary and secondary outcomes are consolidated in Table 2. Specifically, implementation of the SNDR technique was associated with a significant improvement in dialysis efficacy. The median single-pool Kt/V increased from 1.08 (IQR, 0.82-1.25) pre-SNDR to 1.46 (IQR, 1.38-1.55) post-SNDR (P < 0.001). A concordant improvement was observed in the urea reduction ratio (URR), which increased from a median of 65% (IQR, 55-72) to 79% (IQR, 75-82) (P < 0.001).

Table 2.

Summary of Primary and Secondary Outcomes Before and After Implementation of the SNDR Technique

Outcome Measure	Pre-SNDR, Median (IQR)	Post-SNDR, Median (IQR)	P Value
Primary Outcomes
Single-pool Kt/V	1.08 (0.82-1.25)	1.46 (1.38-1.55)	<0.001
Urea reduction ratio, %	65 (55-72)	79 (75-82)	<0.001
Annualized reintervention rate, events/y	3.7 (2.2-5.1)	0.36 (0.00-0.67)	<0.001
Secondary Outcomes
Ultrafiltration achievement ratio, %	72 (58-88)	98 (95-100)	<0.001
Post-dialysis BNP, pg/mL	1052 (426-1850)	350 (280-450)	0.002
Annualized access cost, ¥10k	13.5 (8.5-17.8)	1.6 (0.0-3.1)	<0.001
Annualized catheter use, events/y	1.3 (0.9-1.7)	0.0 (0.0-0.0)	<0.001
Safety Outcomes
Machine alarms, per 100 sessions	28 (21-35)	3 (2-5)	<0.001
Hematoma rate, % of sessions	8.0 (6.0-10.5)	1.5 (1.0-2.0)	<0.001
Mean venous pressure, mm Hg	124 (116-134)	118 (112-125)	0.15

Furthermore, the efficacy of fluid removal was markedly enhanced. The ultrafiltration achievement ratio (actual/prescribed volume) increased from a median of 72% (IQR, 58-88) pre-SNDR to 98% (IQR, 95-100) post-SNDR (P < 0.001). This improved fluid management was associated with a significant amelioration of cardiovascular volume status, as evidenced by a substantial reduction in post-dialysis B-type natriuretic peptide (BNP) levels from a median of 1052 pg/mL (IQR, 426-1850) to 350 pg/mL (IQR, 280-450; P = 0.002).

The most pronounced effect was observed on the reintervention burden. The annualized reintervention rate decreased dramatically by 90%, from a median of 3.7 events per patient-year (IQR, 2.2-5.1) pre-SNDR to 0.36 events per patient-year (IQR, 0.00-0.67) post-SNDR (P < 0.001). Notably, six patients (24%) required no reinterventions whatsoever during a median post-SNDR follow-up of 3.8 years. The collective and individual improvements in these parameters are visually presented in Figure 2.

Figure 2.

Significant improvement in dialysis delivery and efficacy after implementation of the SNDR technique. (A) Single-pool Kt/V significantly increased and variability decreased post-SNDR (median [IQR], 1.08 [0.82-1.25] vs 1.46 [1.38-1.55]; P < 0.001). (B) The urea reduction ratio (URR) showed a concordant improvement (65% [55-72] vs 79% [75-82]; P < 0.001). (C) The ultrafiltration achievement ratio (actual/prescribed volume) markedly improved (72% [58-88] vs 98% [95-100]; P < 0.001). (D) Post-dialysis B-type natriuretic peptide (BNP) levels substantially decreased (1052 pg/mL [426-1850] vs 350 pg/mL [280-450]; P = 0.002). (E) Dialysis blood flow rate significantly increased, reflecting improved access patency and hemodynamic stability (215 mL/min [200-230] vs 270 mL/min [260-275]; P < 0.001). (F) Dialysis session achievement (actual/prescribed treatment time) improved substantially, indicating fewer procedure-related interruptions (88% [83-93] vs 100% [99-100]; P < 0.001). Data are presented as box plots (median, IQR, and range) with individual paired points connected by lines. P values were calculated using paired t tests for normally distributed parameters (Kt/V, URR, UF ratio, blood flow rate) and the Wilcoxon signed-rank test for non-normally distributed data (BNP, session achievement).

Secondary outcomes: economic and clinical impact

The reduction in procedural burden translated into substantial economic savings. The median annualized access-related cost decreased substantially by 88%, from ¥135,000 (IQR, ¥85,000-¥178,000) pre-SNDR to ¥16,000 (IQR, ¥0-¥30,800) post-SNDR (P < 0.001). Consistent with this, the need for temporary catheter support was virtually eliminated. The annualized catheter use rate dropped from 1.3 events per year (IQR, 0.9-1.7) to 0.00 events per year (IQR, 0.00-0.00) (P < 0.001), with 22 patients (88%) requiring no catheters during the entire follow-up period.

Safety outcomes

The SNDR technique also demonstrated a favorable safety profile. Dialysis machine alarms related to vascular access issues (eg, high venous pressure) decreased significantly from a median of 28 (IQR, 21-35) to 3 (IQR, 2-5) events per 100 sessions (P < 0.001). The incidence of needle cannulation-related hematomas requiring intervention was reduced from 8.0% (IQR, 6.0-10.5) to 1.5% (IQR, 1.0-2.0) of sessions (P < 0.001). Finally, mean intradialytic venous pressure remained within a safe and comparable range post-SNDR, with a median of 124 mmHg (IQR, 116-134) pre-SNDR versus 118 mmHg (IQR, 112-125) post-SNDR (P = 0.15). The significant reductions in reintervention burden, costs, catheter dependence, and procedure-related adverse events are comprehensively depicted in Figure 3.

Figure 3.

Clinical effectiveness and safety outcomes of the SNDR technique in salvaging failing arteriovenous fistulas. (A) Annualized reintervention rate decreased dramatically post-SNDR (median [IQR], 3.7 [2.2-5.1] vs 0.36 [0.00-0.67] events per patient-year; P < 0.0001). (B) Annualized access-related costs reduced substantially (135,000 [85,000-178,000] vs 16,000 [0-30,800] Chinese Yuan; P < 0.0001). (C) Annualized temporary catheter use was virtually eliminated (1.3 [0.9-1.7] vs 0.0 [0.0-0.0] events per year; P < 0.0001). (D) Dialysis machine alarm rate related to vascular access issues decreased significantly (28 [21-35] vs 3 [2-5] events per 100 sessions; P < 0.0001). (E) Rate of cannulation-related hematomas requiring intervention was reduced (8.0% [6.0-10.5] vs 1.5% [1.0-2.0] of sessions; P < 0.0001). (F) Mean intradialytic venous pressure remained within safe and comparable ranges (124 [116-134] vs 118 [112-125] mm Hg; P = 0.15, NS). Data are presented as box plots (median, IQR, and range) with individual paired points connected by lines. All comparisons were made using the Wilcoxon matched-pairs signed-rank test. Abbreviation: NS, not significant.

Discussion

This single-center, retrospective study demonstrates that the novel single-needle distal return (SNDR) technique is a highly effective and safe salvage strategy for patients with complex and exhausted arteriovenous fistulas. Our findings indicate that SNDR not only sustains but significantly enhances dialysis efficacy, as evidenced by marked improvements in Kt/V, URR, and ultrafiltration achievement, while simultaneously producing a dramatic 90% reduction in reintervention burden and an 88% decrease in access-related costs. The near-elimination of temporary catheter use and the significant reduction in adverse events further underscore the technique’s role in mitigating the substantial clinical and economic burdens associated with conventional management of failing AVFs.

The superior dialysis efficacy achieved with SNDR is underpinned by a fundamental improvement in the delivery and execution of the dialysis prescription. First, the technique completely eliminates access recirculation, a critical flaw in stenotic fistulas, in which dialyzed blood is short-circuited back to the dialyzer, crippling solute clearance.^22,23 By spatially separating the arterial and venous needles into different limbs, SNDR ensures that fully systemic, urea-rich blood is always presented for purification.²⁴ Second, and equally important, the creation of this novel hybrid vascular circuit directly addresses the primary flow limitations of the failing AVF. As evidenced by the increased blood flow rates and achieved dialysis session duration, the SNDR pathway offers significantly improved patency and hemodynamic stability compared with the preintervention state. This eliminates the frequent disruptions, mandatory flow reductions, and premature session termination caused by high venous pressure alarms, needle repositioning, or post-PTA complications that previously plagued these patients.25, 26, 27, 28 The consistent normalization of venous pressure with the SNDR circuit (Fig 3F) is the most direct explanation for the marked reduction in venous pressure-related machine alarms (Fig 3D), which in turn was a major contributor to the improved session continuity and achievement of prescribed treatment time. Consequently, clinicians can consistently deliver the prescribed dialysis dose—both in terms of solute clearance and fluid removal—for the full treatment time, a foundational prerequisite for adequacy that was previously unattainable.

The reliable delivery of dialysis directly translates into the observed cardiovascular benefits. The consistent achievement of ultrafiltration goals without interruption mitigates the hemodynamic swings associated with erratic fluid removal, whereas the reduction in access-related complications lowers chronic inflammatory stress.^29,30 The significant decrease in BNP levels is a direct biomarker of this improved volume control and reduced cardiac strain.³¹ Economically, the dramatic reduction in reinterventions is the primary driver of cost savings. By providing a durable and stable access solution, SNDR breaks the costly cycle of repeated PTA procedures, hospitalizations, and catheter placements that characterize the management of these complex cases.

Crucially, our experience, corroborated by long-term data from Japan, definitively challenges the conventional skepticism regarding the durability of superficial veins for repeated cannulation.^18,19,24 The strategic implementation of a bilateral rotation protocol, combined with adjuvant far-infrared therapy, proved that veins of the lower extremities, such as the dorsalis pedis and saphenous tributaries, can develop venous capacitance and withstand long-term needling with a low complication profile. This finding alone has profound implications for preserving upper extremity vascular capital.

Looking beyond its role as a salvage therapy, the principles of SNDR suggest a potential paradigm shift in vascular access management with broader applications. The reduction in cannulation-related trauma to the native AVF presents a compelling rationale for its prophylactic use in preserving newly created or immature fistulas (AVFs) and arteriovenous grafts (AVGs), potentially extending their functional lifespan from the outset.^11,12,32 Moreover, by diverting a significant portion of venous return away from the central venous system via the lower extremities, SNDR may inherently reduce the risk of central venous stenosis, a devastating and often irreversible complication of long-term hemodialysis.^11,32 This attribute could make it a valuable strategy for patients with existing or developing central venous issues.^12,32 Looking ahead, the widespread adoption of SNDR need not be confined to complex salvage scenarios. Its principles hold significant promise for routine application in both AVFs and AVGs, particularly in patients with limited vascular capital who are at high risk of vascular exhaustion—a critical state in which a patient outlives their usable dialysis access sites. By minimizing cannulation damage and systemic sequelae from the outset, SNDR could serve as a pivotal prophylactic strategy to conserve precious vascular resources and secure long-term dialysis viability in this vulnerable population.

Our study has several limitations. Its retrospective design and modest sample size from a single center may limit the generalizability of the findings. The lack of a concurrent control group treated with continued PTA, while mitigated by the robust self-controlled design, means we cannot fully account for all potential confounding variables. Furthermore, the long-term durability beyond 5 years remains to be established in future studies with extended follow-up.

In conclusion, the SNDR technique successfully addresses the dual challenge of maintaining dialysis adequacy and eliminating procedural burden in a high-risk population. It represents a transformative salvage strategy that can avert catheter dependence and its associated morbidity. Future prospective, randomized studies are warranted to validate these findings and to explore its preventive applications in a broader hemodialysis population, ultimately redefining its role from a salvage maneuver to a mainstream strategy for vascular access preservation.