The use of mechanical circulatory support (MCS) devices such as Impella® (Abiomed), intra-aortic balloon pump (IABP), extracorporeal membrane oxygenation (ECMO), and TandemHeart® (TandemLife) for cardiogenic shock or high-risk percutaneous coronary interventions (PCI) has steadily increased in recent years. All of these devices require large-bore arterial access and increase the risk for access-related vascular complications and bleeding. Similarly problematic in terms of bleeding and access-related complications are other procedures requiring large-bore access, such as transcatheter aortic valve replacement (TAVR), endovascular aneurysm repair (EVAR), and thoracic endovascular aortic repair (TEVAR). All of these percutaneous interventions have created new challenges for femoral and overall arterial access management.