Abstract
Venous access selection represents a pivotal aspect of permanent pacemaker implantation, directly influencing both procedural safety and long-term device performance. Although the subclavian vein has been traditionally favored, its use is associated with notable risks, including pneumothorax, hemothorax, and crush syndrome. In contrast, axillary access has gained prominence, supported by observational studies and a small number of randomized trials demonstrating reduced pneumothorax rates, fewer arterial punctures, and potentially fewer long-term mechanical lead failures, particularly when ultrasound guidance is used. However, these findings are derived from heterogeneous studies with variable definitions, imaging protocols and operator experience, highlighting that evidence quality remains moderate. Contemporary advances—such as routine ultrasound guidance, micropuncture techniques, and structured training—have improved procedural consistency and safety, a trend reflected in recent guidelines. This review provides a focused appraisal of complication patterns, anatomical differences and patient-specific considerations to support individualized and evidence-aligned venous access selection in modern clinical practice.