BACKGROUND Conventional guidewire techniques are not always sufficient to restore arteriovenous graft patency in patients with challenging vascular scenarios. We discuss a novel approach to the treatment of chronic total occlusion of the venous outflow tract to enable successful arteriovenous graft thrombectomy. METHODS A 28-year-old female with end-stage renal disease on chronic hemodialysis and recurrent arteriovenous graft thromboses presented with a clotted thigh graft. An existing ipsilateral common femoral vein stent was found to be chronically occluded, causing persistent venous outflow obstruction and rendering an initial attempt at thrombectomy unsuccessful due to wire buckling and the inability to navigate through the stent chronic total occlusion. RESULTS After establishing femoral vein access, a vibrational recanalization device was used to cross the occluded stent. The device was then removed, permitting routine angioplasty. Post-angioplasty angiogram revealed persistent intra-stent stenosis, so a covered stent was deployed with good angiographic results. Routine pharmaco-mechanical thrombectomy of the arteriovenous graft was then performed. Two additional stents were placed due to stenotic recoil in the venous limb of the graft. Angioplasty was also performed at the arteriovenous graft arterial anastomosis. Repeat imaging demonstrated marked improvement in the graft blood flow. CONCLUSIONS Total occlusion of the venous outflow tract prevents adequate blood flow through an arteriovenous graft and undermines successful thrombectomy. We describe the use of the Crosser vibrational recanalization device for the safe and effective treatment of a chronic total occlusion of the venous outflow tract, thus extending the life of the patient's vascular access for hemodialysis.