Bleeding may also be a marker of comorbidities associated with worse prognosis (eg, occult cancer). The risk of bleeding is associated with a number of patient factors (eg, advanced age, low body mass index, CKD, baseline anemia), as well as the degree of platelet and thrombin inhibition, vascular access site, and sheath size.267 269 The overall approach to PCI should be individualized to minimize both ischemic and bleeding risks. Measures to minimize the risks of bleeding complica- tions are discussed in several sections of this guideline. These include use of anticoagulation regimens associated with a lower risk of bleeding, weight-based dosing of heparin and other agents, use of activated clotting times to guide unfractionated heparin (UFH) dosing, avoidance of excess anticoagulation,349 dosing adjustments in patients with CKD (eg, eptifibatide, tirofiban, bivalirudin),350 use of radial artery access site,255 and avoidance of femoral vein cannulation when possible. Vascular closure devices have not been clearly demonstrated to decrease bleeding complications and are discussed in detail in Section 5.11. 4.8. PCI in Hospitals Without On-Site Surgical Backup: Recommendations Class IIa 1. Primary PCI is reasonable in hospitals without on-site cardiac surgery, provided that appropriate planning for program development has been accom- plished.351,352 (Level of Evidence: B) Class IIb 1. Elective PCI might be considered in hospitals with- out on-site cardiac surgery, provided that appropri- ate planning for program development has been accomplished and rigorous clinical and angiographic criteria are used for proper patient selection.352 354 (Level of Evidence: B) Class III: HARM 1. Primary or elective PCI should not be performed in hospitals without on-site cardiac surgery capabilities without a proven plan for rapid transport to a cardiac surgery operating room in a nearby hospital or without appropriate hemodynamic support capa- bility for transfer. 