An operator's ability to determine the optimal vascular access strategy for patients undergoing peripheral endovascular intervention is critical to maximizing procedural safety and success. Individualizing an approach to access requires careful planning, and is contingent upon a solid general knowledge of normal and abnormal vascular anatomy, as well as the particulars of each patient's history, physical examination, and non-invasive test results. An awareness of the technical nuances, relative safety, and indications for obtaining percutaneous arterial access at all potential sites is essential. Available means for approaching lower extremity arterial disease include the retrograde and antegrade common femoral approaches, the contralateral crossover technique, upper extremity approaches from the radial, brachial, or axillary arteries, or occasionally retrograde access via the popliteal, dorsalis pedis, or tibial arteries. These techniques, as well as important considerations for approaching disease of the renal, subclavian, and carotid arteries are reviewed.