**1. Introduction**

Patients suffering from end-stage renal disease (ESRD) treated with renal replacement therapy is a continuously growing population [1–3]. Hemodialysis is the most preferable modality among them [4], making a suitable permanent vascular access (VA) vital for their treatment. The ultimate purpose is the successful creation of a well-functioning, long-lasting VA, capable of delivering adequate dialysis to the patient with the minimum of complications under its appropriate management. In the last years in this field of nephrology, very few changes have taken place. Three types of permanent VA are in use, arteriovenous fistula (AVF), arteriove‐ nous grafts (AVGs), and cuffed central venous catheters (CVCs). Long-lasting survival, adequate blood flow, and low complications rate are necessary characteristics of them. Native forearm AVF best fulfills this criteria and is the first choice of VA, the first native arteriovenous fistula (AVF) described in 1966 by Brescia and Chimino [5]. The second choice is upper arm AVF, followed by AVG and last one cuffed CVC [6–8]. Vascular access dysfunction is respon‐ sible for 20% of dialysis patients' hospitalizations in the USA [9], making it one of the most important causes of morbidity [10], while the annual cost of VA creation and maintenance is over 1 billion dollars yearly [11], with arteriovenous graft (AVG) cost be more than fivefold higher than AVF [12]. Thus, VA is called the "Achilles' heel" of hemodialysis [13].
