The evolution of interventional cardiology has seen a paradigm shift from traditional access through large femoral artery to transradial access and more recently to the smaller vessel of the hand with distal radial access (DRA). The sheathless approach to DRA offers numerous advantages. While keeping the outer diameter small by omitting the sheath, it allows for a larger inner lumen of the guiding catheters, facilitating safer manipulation during complex procedures and at the same time reducing the device-to-artery ratio, which is critical to minimizing vascular complications. The sheathless approach also provides greater stability of the guiding catheter, reducing the risk of loss of position. Recent advances in sheathless catheter technology, such as the Eaucath and Railway systems, demonstrate improved outcomes, including reduced rates of radial artery occlusion and spasm. This chapter reviews the anatomical and procedural considerations for a sheathless DRA approach for percutaneous coronary intervention, the development of dedicated sheathless systems, and their implications for future interventional strategies.