Few situations are as vexing for vascular surgeons and their patients as the need for placement of permanent dialysis access when very few access sites remain viable. We recently encountered a patient who typifies this group. After venoplasty of the patient's right femoral and iliac veins, we placed a right superficial femoral artery to inferior vena cava 6-mm polytetrafluoroethylene graft. Under fluoroscopic guidance, we placed the venous limb of the graft directly into the inferior vena cava using a 24-French Gore thoracic aortic graft (TAG) introducer sheath. We secured the venous limb with a purse-string suture at the entrance site in the femoral vein. A standard end-to-side arterial anastomosis was performed. The access has worked without issue for over a year at this point.