Introduction: We have innovated ultrasound (US) guided vascular access for pacemaker implantation through two iterations. Hypothesis: We sought to determine success rates and complications arising from a variety of vascular access strategies in our practice amongst a large number of consecutive patients undergoing first permanent pacemaker implantation. Methods: From September 2009 to April 2017 there were 2091 attempted first permanent pacemaker implants by nine operators with five primary vascular access strategies: Traditional bony land mark and Xray screening guided subclavian vein puncture, venogram and Xray screening axillary vein puncture, open cephalic vein isolation and cannulation, US guided axillary vein puncture using a 70mm 14G needle, and US guided axillary or cephalic vein puncture using a 30mm 21G needle. Outcomes were failure to complete the implant due failed vascular access, pneumothorax (PT) not requiring intervention, PT requiring intervention, and haemothorax. Pneumo/haemothorax due to pacemaker lead tip perforation were excluded. Results: See table Conclusions: US guided access was more strongly associated with achieving venous access by primary intent. Open cephalic cannulation was associated with the lowest failed access rate. US guided access with smaller (30mm 21G) needles was associated with the lowest access related complication rate (0/285) and higher rates of right sided and percutaneous cephalic venous access. We recommend small needle US guided venous access as a primary approach for pacemaker implantation. [ABSTRACT FROM AUTHOR]