Objective To evaluate the efficacy and safety of sharp recanalization using a trans-septal needle as a salvage technique for chronic and total occlusion (CTO) of the right brachiocephalic vein in hemodialysis patients after failure of conventional guidewire recanalization.  Methods  A retrospective analysis was conducted on 53 hemodialysis patients with right brachiocephalic vein CTO treated at West China Hospital of Sichuan University between January 2018 and December 2024. All patients initially underwent conventional guidewire recanalization, and 34 of the 53 patients with failed conventional recanalization subsequently received salvage sharp recanalization using a trans-septal needle. Technical success rate, complication rate, and primary and secondary patency rates at 3, 6, and 12 months were compared between the two groups.  Results  The technical success rate was 100.0% (19/19) in the conventional recanalization group and 94.1% (32/34) in the trans-septal needle group, with no significant difference between the two groups (P=0.540). The complication rates were 10.5% and 17.6%, respectively, also showing no significant difference (P=0.704). Patency rates were estimated using the Kaplan-Meier method and compared with the log-rank test. No significant differences were observed in primary patency rates at 3, 6, and 12 months (conventional group: 89.47%, 78.95%, and 57.89%; trans-septal needle group: 91.18%, 79.42%, and 58.82; χ²=0.902, 1.127, and 0.762, respectively) or in secondary patency rates (conventional group: 84.21%, 73.68%, and 68.42%; trans-septal needle group: 94.12%, 85.29%, and 61.76; χ²=0.502, 0.927, and 1.156, respectively), with all P values ＞0.05. Notably, the occlusion length was significantly longer in the trans-septal needle group than in the conventional recanalization group (28.72±5.13mm vs. 23.31±6.82mm, t=3.213, P＜0.01).  Conclusion  For hemodialysis patients with right brachiocephalic vein CTO in whom conventional guidewire recanalization fails, sharp recanalization using a trans-septal needle is an effective and safe salvage technique. Its short- and mid-term patency outcomes are comparable to those achieved in patients with successful conventional recanalization, and it may be particularly suitable for long-segment, fibrotic, or calcified complex lesions.