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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 \u201curemic mismatch\u201d 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.<\/jats:p>","DOI":"10.1021\/acsbiomaterials.6c00469","type":"journal-article","created":{"date-parts":[[2026,9,10]],"date-time":"2026-09-10T08:01:34Z","timestamp":1789027294000},"page":"5145-5158","source":"Crossref","is-referenced-by-count":0,"title":["Bioengineered Vascular Grafts for Hemodialysis Access: Design Requirements, Clinical Evidence, and Translational Barriers"],"prefix":"10.1021","volume":"12","author":[{"given":"Suqi","family":"Rui","sequence":"first","affiliation":[{"name":"Nanjing Gaochun People\u2019s Hospital , , ,","place":["Nanjing, Jiangsu, China, 211300"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0002-4929-7506","authenticated-orcid":true,"given":"Junjie","family":"Chen","sequence":"additional","affiliation":[{"name":"Chengdu University of Traditional Chinese Medicine , , ,","place":["Chengdu, Sichuan, China, 611137"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lei","family":"Tian","sequence":"additional","affiliation":[{"name":"Children\u2019s Hospital of Nanjing Medical University , , , ,","place":["Nanjing, Jiangsu, China, 210008"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"316","published-online":{"date-parts":[[2026,9,10]]},"reference":[{"issue":"1","key":"2026101202062578800_cit1","doi-asserted-by":"publisher","first-page":"280","DOI":"10.1016\/j.jvs.2025.09.040","article-title":"Outcomes of Snuffbox Arteriovenous Fistula as a First-Line Approach to Dialysis Access in Patients with End-Stage Kidney Disease","volume":"83","author":"Khalaf","year":"2026","journal-title":"J. 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