Objective: Roadmap fluoroscopy has never previously been evaluated for axillary vein puncture in clinical practice. Our retrospective cohort study was performed to investigate the efficacy and safety of axillary vein puncture real-time guided by roadmap fluoroscopy in cardiac pacemaker implantation. Methods and Results: A total of 178 patients undergoing axillary vein puncture in permanent pacemaker implantation were included in the present cohort study during a 1-year period at our institution. All procedures were performed by the operators with previous experience in axillary approach. Primary endpoint was defined as axillary vein success rate. Secondary endpoints were venous access site change, time to obtain venous access, procedural time, and complication rate. For the primary outcomes, a higher success rate was observed in the roadmap group compared with the blind puncture group (95.2% vs 78.7%; P<0.001), as well as a lower rate of venous access site change (7.1% vs 35.1%; P <0.001) and shorter time to obtain venous access and procedural time, with lower complications (3.6 % vs 6.4 %; P<0.01). Conclusion: The roadmap fluoroscopy real-time guided axillary venous access is safer and has a better success rate and faster execution time compared with the blind axillary puncture in cardiac pacemaker implantation. However, further larger scale prospective randomized controlled trials are required to confirm the findings.