Objectives: To compare the success and complication rates of ultrasound-guided or palpation-guided punctures of the common femoral artery in a prospective randomized study. Background: Percutaneous femoral arterial access is sometimes difficult to perform and is the source of complications. It has not been established whether ultrasound-guided puncture of the common femoral artery is the standard practice for angiography. Materials and Methods: Two hundred and eight patients were randomized into two groups. One had ultrasound-guided puncture and the other had palpation-guided puncture of the common femoral artery. The technical success, first pass success rate, total number of attempts required for access, time to sheath insertion, pain during puncture, and access-related complication were compared. Results: Technical success tended to be higher and the complication rates tended to be lower in the ultrasound-guided group but the difference did not reach statistical significance (P = 0.052 and P = 0.052). The first pass success rate was higher, total number of attempts required for access and time to sheath insertion were lower in the ultrasound-guided group. Atheromatous plaques on the common femoral artery, iliac artery obstructive lesion, previous ipsilateral puncture of the common femoral artery, obesity, and blood pressure during puncture did not change the outcome. Conclusions: Ultrasound guidance improves secondary outcomes of the common femoral artery puncture when compared to palpation-guided puncture. Technical success and complication rates seem lower in the presence of ultrasound guidance but larger study populations are needed to verify the result. (C) 2013 Wiley Periodicals, Inc.