BACKGROUND: The aim of this randomized controlled study was to compare the primary success rate between venous cutdown and the Seldinger technique for placement of the totally implantable venous access port (TIVAP). METHODS: A total of 152 patients were randomized to receive TIVAP placement by either venous cutdown or the Seldinger technique. The main endpoint was the primary success rate. Secondary endpoints included overall success rate, procedure time and perioperative complication rates. Multiple logistic regression analysis was undertaken to assess the influence of different variables on primary success. RESULTS: The primary success rate was 71 per cent for venous cutdown and 90 per cent for the Seldinger technique (P = 0.007). The mean procedure time was significantly shorter for the Seldinger technique (48.9 versus 64.8 min; P < 0.001). The overall success rate was 97.4 per cent. The rate of perioperative complications was similar for the two approaches (5 per cent), but was higher when a procedure was converted. The variables sex, body mass index, implantation side and surgeon experience had no impact on the primary success rate. CONCLUSION: The Seldinger technique was more effective and quicker than venous cutdown, and should be regarded as the method of choice for TIVAP placement. Registration number: NCT00272623 (http://www.clinicaltrials.gov).