BACKGROUND: We prospectively evaluated the effect of insertion angle on the visibility of echogenic and nonechogenic needles in phantoms and in axillary nerve blocks in patients. METHODS: Conventional and echogenic needles were studied in phantoms at insertion angles of 0-30°, 30-45°, and ≥ 45°. Operators rated comfort and image quality during the procedure and experts blinded to the needle groups randomly analyzed videos for tip and shaft visibility, surrounding tissue visibility, sharpness of the needle surface, and percentage of time with the needle completely visible. Patients scheduled for axillary nerve block were prospectively enrolled in the clinical study. Needle insertion angles were 0-30° for the median nerve approach, 30-45° for the radial nerve, and ≥ 45° for the musculocutaneous nerve. The same needle parameters were analyzed during the procedure and on videos. RESULTS: Physician comfort and image quality were significantly better for echogenic needles for phantoms and patients at 30-45° and ≥ 45° insertion angles. Needle tip and shaft visibility at 30-45° and ≥ 45° insertion angles in phantoms and for the musculocutaneous nerve in patients were significantly improved, as well as the percentage with complete needle visualization during the procedure. Tissue visibility and needle sharpness were significantly superior for conventional needles. There were no differences concerning block parameters and adverse events. CONCLUSION: Needles with enhanced echogenicity improved physician comfort, image quality, needle visibility, and visualization time of the needle during ultrasound-guided procedures in phantoms and axillary nerve blocks using insertion angles of 30-45° and ≥ 45°.