We identified multiple access attempts as an area where procedural safety could be improved. Use of ultrasound guidance in obtaining vascular access is becoming widely accepted.19 Ultrasound guidance may increase the accuracy of venous access and potentially reduce bleeding complications by minimizing the chance of inadvertent arterial puncture. Routine use of this technique in patients being considered for catheter-directed fibrinolysis may reduce the number of failed venous access attempts. While we found no difference in major bleeding between patients in which venous access was guided by ultrasound and those in which it was not, the relatively small number of major bleeding events may have limited our ability to detect a difference. Other potential strategies to reduce major bleeding complications are to use upper extremity veins (e.g. cephalic) that are not adjacent to an artery and to utilize micro-puncture access needles.