Percutaneous arterial access is performed in up to 10 million patients worldwide annually. The predominant techniques have been largely unchanged for a half century, but an evolving evidence base over the past several years suggests that major improvements in access and a reduction in complication rates may be accomplished with a better appreciation of anatomy and the use of fluoroscopy or ultrasound guidance. Vascular closure is still predominantly by manual compression; meta-analyses comparing vascular closure techniques have not clearly demonstrated a difference between manual compression and vascular closure device complication rates. Although vascular closure devices are associated with earlier hemostasis and time to ambulation, their cost and potential associated complications limit use to roughly 30% of cases in the United States and single digit percentages in the rest of the world.