**2. Choice of anesthesia**

After the evaluation of the patient's physical condition, anesthesia method should be decided. Anesthetic options include local anesthetic (LA) infiltration around the operative site provided by the surgical team in combination with monitored anesthesia care and sedation (MAC (Monitored Anesthesia Care)) provided by the anesthesia team, regional anesthesia (RA), and general anesthesia (GA). Choice of anesthesia also depends on the surgical site and the type of surgery. The surgery for vascular access for hemodialysis can essentially be categorized into two basic types such as arteriovenous fistulas (AVF) and arteriovenous grafts (AVG).

For AVF, a fistula is created between an artery and a vein. There are two common sites in the upper extremity where a fistula is created: between the radial artery and cephalic or basilic vein at the wrist and between the brachial artery and cephalic or basilic vein in the upper arm. For AVF created with the basilic vein, transposition of the vein is required, affecting the chosen anesthesia method. Alternatively, AVG is placed using prosthetic material between an artery and vein in the forearm or upper arm. Any of the three options (LA, RA, and GA) are acceptable for both AVF and AVG. However, the patient's medical comorbidities, the anatomic location (wrist/ forearm, antecubital fossa, and upper arm), and the surgeon's preference are to be considered when selecting the anesthesia method.

Choice of anesthetic options can be determined based on the anatomic location of surgical incision. LA with MAC can be considered suitable for the procedures performed at the wrist and the antecubital fossa. RA is a viable option for procedures performed at the antecubital fossa and distal upper arm. GA or RA with an interscalene block can be considered when procedures involve the proximal upper arm for AVG and transpositions, which require tunneling.
