We introduce a technique for treating chronic limb-threatening ischemia with superficial femoral artery flush occlusion, facilitating intravascular treatment when conventional anterograde puncture is challenging. This retrospective study reviewed 37 patients who underwent vascular sheath fenestration assisted anterograde puncture to complete endovascular treatment for chronic limb-threatening ischemia from December 2022 to December 2023. All patients had superficial femoral artery flush occlusion, meeting chronic limb-threatening ischemia diagnostic criteria. Evaluations included intraoperative radiation dose, technical success rate, patency rate, limb retention rate, and postoperative complications from surgery to a 12-month follow-up. The mean age of the patients was 70 ± 10 years, with an age range of 46 to 90 years. A significant proportion of the cases presented with severe chronic limb-threatening ischemia, with 78.4% classified as Rutherford ≥ 5, 51.3% as WiFi ≥ 3, and 97.3% as Global Limb Anatomic Staging System III. In all surgical procedures, a plain old balloon angioplasty was utilized for anterograde dilation. Subsequently, based on angiographic findings, treatment involved either drug-coated balloon dilation combined with stent implantation or drug-coated balloon dilation alone. Successful revascularization was achieved in all cases, resulting in marked clinical and hemodynamic improvements, as evidenced by the mean ankle-brachial index increasing from 0.49 preoperatively to 0.86 postoperatively. The 12-month follow-up outcomes were as follows: limb salvage rate of 94.6%, primary patency rate of 83.8%, assisted primary patency rate of 91.9%, and secondary patency rate of 94.6%. The incidence of postoperative complications was 8.1%. The average duration of hospital stay was 8.43 ± 2.72 days. The vascular sheath fenestration assisted anterograde puncture technique demonstrates favorable surgical outcomes and merits consideration as a viable treatment option for chronic limb-threatening ischemia patients with superficial femoral artery occlusion.