The tunnelled catheter (Hickman, Broviac, Demers) is always used if infection with bacteria, if at all possible, must be avoided.
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What are the advantages of a tunnelled catheter?
The advantages of a tunnelled catheter lie in the fact that they can be used for a long time. They can usually be used for 3 to 12 months (by way of comparison, a CVC is used for around 14 days). If there are no alternatives available, the time in site may have to be prolonged in isolated cases – provided the patient is tolerating the catheter well and there is a clinical need for it.
Crucial for the length of use is that bacterial colonisation is delayed for as long as possible or ideally prevented altogether. This is necessary for dialysis patients, for example, who are dependent on complication-free and ideally quick dialysis procedures several times a week and in some circumstances for their entire lives.
Long-term use is especially important for
- chemotherapy or the administration of other medications (particularly Hickman catheters).
- the administration of higher-viscosity solutions, e.g. for parenteral nutrition bypassing the gastrointestinal tract (especially Broviac catheters).
Construction of the tunnelled catheter
Tunnelled catheters differ from a conventional CVC by virtue of two characteristics:
- a longer distance between the skin incision and vessel entry below the skin (subcutaneous) serves as a barrier to bacteria between the outside world and the vascular system (principle of reducing the risk of a systemic infection, i.e. one that spreads through the blood system). This is how the term "tunnelled catheter" is derived.
- A type of cuff made from polyester fibres (Dacron) which is attached to the catheter’ subcutaneous run for around 1 cm along the shaft acts as an additional barrier to bacteria. The Dacron cuff grows slightly into the fatty tissue below the skin over time, helping to also prevent any unwanted movement (dislocation) of the catheter. The polyester cuff can also be equipped with an antibiotic coating.
Apart from these characteristics, the tunnelled catheter is designed like other CVCs (see separate section on these).
How is a tunnelled catheter implanted?
Generally speaking, the catheter is implanted under local anaesthetic in the neck above the collar bone (vessel entry site of the catheter centrally) and at the lateral anterior chest wall (catheter exit site out of the body) – the catheter runs “tunnelled” underneath the skin (subcutaneously) between these two sites. Less commonly, the vessel entry point is also located below the collar bone and in a few justified exceptions even in the groin (the catheter exit point is then modified accordingly).
Each lumen on the side external to the body is sealed off (for safety’s sake, several times). To protect it against inadvertent slipping (dislocation), for example during sleep, the tunnelled catheter is secured to the patient (using a fixation suture and/or fixation plaster). With a good knowledge of anatomy, the puncture can be performed “blind”, or with ultrasound guidance in an aseptic environment.
We insist on the following quality criteria when siting a tunnelled catheter:
- they are always inserted under sterile conditions (maximum sterile barrier principle) following careful disinfection of the skin and draping with a sterile cover and gloves, including face mask and hood.
- The catheter can be inserted under local anaesthetic or more extensive medication through to general anaesthesia by an anaesthetist.
- The actual puncture of the vessel is always guided by ultrasound in order to avoid complications (see Figure 2 and video 1: more detailed video documentation on ultrasound-guided venepuncture which is worth watching can be found in the New England Journal of Medicine, for example (3, 4)).
- The CVC is always sited using as safe and gentle a catheter placement technique as possible (Seldinger technique (5)) under X-ray guidance.
- To complete the procedure, a check X-ray is carried out while the patient is still on the implant table in order to rule out any possible complications (such as a pneumothorax).
What are the risks of implantation?
The combination of ultrasound-guided venepuncture and fluoroscopy-guided (with X-rays) placement of the tunnelled catheter means that the potential risks can be reduced to a very low level. Potential risks include bleeding and bruising, the missed puncture of the jugular artery or subclavian artery, infection or the formation of an abscess, thrombosis of the vein or catheter, the introduction of air into the pleural fissure (pneumothorax) or injury to neighbouring organs.
- Broviac JW, Cole JJ, Scribner BH. A silicone rubber atrial catheter for prolonged parenteral alimentation. Surg Gynecol Obstet. 1973 Apr;136(4):602-6. PubMed PMID: 4632149
- Hickman RO, Buckner CD, Clift RA, Sanders JE, Stewart P, Thomas ED. A modified right atrial catheter for access to the venous system in marrow transplant recipients. Surg Gynecol Obstet. 1979 Jun;148(6):871-5. PubMed PMID: 109934.
- Shaldon S, Silva H, Pomeroy J, Rae AI, Rosen SM. Percutaneous femoral venous catheterization and reusable dialysers in the treatment of acute renal failure. Trans Am Soc Artif Intern Organs. 1964;10:133-5. PubMed PMID: 5878400.
- Zieschang M, Erben B, Höffler D, Niemeyer R, Schielke DJ, Siebold G, Strack G. The Demers atrial catheter: experience with a single-lumen silicone catheter as short- and long-term access for hemodialysis. Clin Nephrol. 1995 Aug;44(2):113-7. PubMed PMID: 8529298.
- Graham AS, Ozment C, Tegtmeyer K, Lai S, Braner DA. Videos in clinical medicine. Central venous catheterization. N Engl J Med. 2007 May 24;356(21):e21. PubMed PMID: 17522396.
- Ortega R, Song M, Hansen CJ, Barash P. Videos in clinical medicine. Ultrasound-guided internal jugular vein cannulation. N Engl J Med. 2010 Apr 22;362(16):e57. doi: 10.1056/NEJMvcm0810156. PubMed PMID: 20410510.
- Seldinger SI. Catheter replacement of the needle in percutaneous arteriography; a new technique. Acta radiol. 1953 May;39(5):368-76. PubMed PMID: 13057644.
- O’Grady NP, Alexander M, Burns LA, Dellinger EP, Garland J, Heard SO, Lipsett PA, Masur H, Mermel LA, Pearson ML, Raad II, Randolph AG, Rupp ME, Saint S; Healthcare Infection Control Practices Advisory Committee. Guidelines for the prevention of intravascular catheter-related infections. Am J Infect Control. 2011 May;39(4 Suppl 1):S1-34. doi: 10.1016/j.ajic.2011.01.003.
- O’Grady NP, Alexander M, Dellinger EP, Gerberding JL, Heard SO, Maki DG, Masur H, McCormick RD, Mermel LA, Pearson ML, Raad II, Randolph A, Weinstein RA. Guidelines for the prevention of intravascular catheter-related infections. Centers for Disease Control and Prevention. MMWR Recomm Rep. 2002 Aug 9;51(RR-10):1-29.
- Gebauer B, Beck, Wagner HJ. Zentralvenöse Katheter: Diagnostik von Komplikationen und therapeutische Optionen. Radiologie up2date 2008; 8(2): 135-154 DOI: 10.1055/s-2007-995703