Background The venous access for the insertion of permanent leads of cardiac implantable electronic devices is often achieved by venous cutdown of the cephalic vein, or by “blind” puncture of the subclavian vein using anatomical landmarks, or by fluoroscopy‐assisted methods. Methods We have retrospectively analyzed our clinical experience to verify the feasibility, the safety, and efficacy of the adoption of ultrasound‐guided puncture/cannulation of the axillary vein for this purpose. Results Nine hundred eighty‐seven leads were placed during 548 consecutive procedures, accessing the axillary vein in the infraclavicular area using real‐time ultrasound guidance. Venipuncture was successful in 99.8% of cases. The access time was 11 seconds (range 4‐580). We recorded three cases of pneumothorax (0.5%), but no hemothorax and no hemo‐mediastinum. The incidence of local hematoma was 2.1% (12 cases). No injury to the brachial plexus or to the phrenic nerve was recorded. In a follow‐up of 33 months (range 16‐39), we observed no cases of “subclavian crush syndrome” (damage of the leads at the level of the thoracic inlet), and the rate of pocket infection/infective endocarditis was 0.7%. Conclusion In our experience, ultrasound‐guided puncture/cannulation of the axillary vein for implantation of permanent leads is feasible, effective, and safe. It might be considered as a first option for this procedure.