The tunnelled catheter (Hickman, Broviac, Demers) is always used if infection with bacteria, if at all possible, must be avoided.

The following tunnelled catheters are implanted in our Radiology Department:

  • Hickman and Broviac catheters
  • Demers or atrial catheters

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).

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).

Figure 2 – The illustration shows the moment of ultrasound-guided venepuncture on the right above the collarbone (the patient’s head is show on the left in the picture). The ultrasound monitor (right-hand side of the picture) shows the vein (long thin arrow in the monitor image) and a bright spot can be seen inside it. This spot represents the tip of the needle and indicates that the vessel has been pierced successfully. The correct positioning is also checked by drawing off a little blood before continuing with the catheter placement.

MdB

Video 1: Illustration of ultrasound-guided venepuncture on the right above the collarbone (the patient’s head is show on the left in the video). The interventional radiologist tracks the introduction of the needle on the ultrasound monitor. On this monitor, the vein appears dark while the tip of the needle is shown as a bright spot. Once the bright spot appears inside the vessel, the radiologist can see that the vessel has been punctured successfully. The correct positioning is also checked by drawing off a little blood before continuing with the catheter placement (video kindly provided by Dr de Bucourt).

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.

Contact


Minimally Invasive Tumour Therapy (MITT)
Charité Campus Virchow-Klinikum (CVK)
Department of Radiology
Augustenburger Platz 1
13353 Berlin

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