There are multiple techniques available for venous access (VA) during cardiac implantable electronic device (CIED) implantation. There is limited data regarding the learning curve with ultrasound (US) guided axillary vein access (USAA). The purpose of this study was to evaluate the safety and efficacy of USAA compared with conventional techniques. This is a single-center prospective randomized control trial of patients with BMI<35 undergoing CIED implantation from May 2020 to May 2021 among 6 implanting physicians (including one US inexperienced fellow, four US inexperienced attendings, and one US experienced attending). After two US-training implantations for US inexperienced operators, patients were randomized 2:1 to USAA versus conventional VA techniques. The primary outcomes were the success rates, VA times and 30-day complication rates. The study included 100 patients (age 68 ± 14 years, 68% men, median BMI 27 ± 4 kg/m2). USAA was successful in 66/70 implants (94%). In all four unsuccessful attempts at USAA, the axillary vein was either too deep or not well visualized. All four had successful VA via alternative methods. Among patients randomized to conventional access, initial attempts at VA included 47% axillary (n=14), 30% (n=9) cephalic, and 23% (n=7) subclavian. The median access time was longer for USAA than conventional access (8.3 IQR 4.2-15.3 minutes vs. 5.2 IQR 3.4-8.6 minutes, p=0.009). Among inexperienced USAA operators, we compared the first vs. last tertile of USAA implants and found a significant improvement in access time (17.0 IQR 7.0-21.0 minutes to 8.6 IQR 4.5-10.8 minutes, p=0.038). The experienced USAA provider had a similar access time with USAA as conventional non-US implants (4.0 IQR 3.3-4.7 minutes vs. 5.2 IQR 3.4-8.6 minutes, p=0.15). Venograms were less common among patients with USAA vs. conventional access (n=1/70 versus n=10/30, p<.0001). The 30-day complication rate was similar in USAA (n=4/70, 6%) vs. conventional access (n=3/30, 10%, p=0.44). No pneumothoraxes occurred in either group. Although the success rate with USAA was high, there was a significant learning curve. Once experienced with the USAA technique, there is the potential for similar access times as conventional techniques and less contrast venography.