Patients with chronic central venous occlusion that need venous access present a challenge to all surgeons. This video displays four difficult cases with a unique solution. The "Inside-Out" technique uses a femoral vein approach to establish internal jugular central access for dialysis catheters, port-a-caths and HeRO grafts. Each case shows unique anatomy and this video explains the steps required to allow Vascular and General surgeons alike to perform this life saving procedure.