A Tunneled Catheter (often referred to as a Permcath) is a long-term dialysis access device used for patients who require hemodialysis. It is commonly employed when other vascular access options, such as arteriovenous fistulas or grafts, are not feasible, and the patient needs an immediate or reliable long-term access point. This catheter insertion process plays a critical role in maintaining effective dialysis, especially for patients undergoing chronic kidney disease management.

What is a Tunneled Catheter (Permcath)?

A Tunneled Catheter (or Permcath) is a specialized catheter inserted into a central vein, typically the internal jugular vein (IJV) or subclavian vein, for the purpose of hemodialysis. Unlike standard central venous catheters, tunneled catheters have a subcutaneous tunnel that helps stabilize the catheter and reduce infection risks. These catheters can remain in place for weeks, months, or even longer, making them a preferred choice for patients with chronic kidney disease (CKD) or those awaiting a more permanent dialysis solution.

Indications for Tunneled Catheter/Permcath Insertion

Tunneled catheter/Permcath insertion is indicated in the following cases:

Chronic Kidney Disease (CKD):

Patients who require long-term hemodialysis but do not have an appropriate vascular access, such as an arteriovenous fistula (AVF).

Emergency Dialysis:

When urgent dialysis is required, and the patient’s fistula or graft is not functional.

Inadequate AVF/Graft

Function: Patients whose arteriovenous access is not functioning adequately or is at risk of failing.

Limited Access Sites:

When other options like peritoneal dialysis or AV fistulas are not viable due to anatomical or medical reasons.

Tunneled Catheter/Permcath Insertion Procedure

The tunneled catheter insertion procedure is a minimally invasive process that typically involves the following steps:

Preparation and Positioning:

The patient is positioned in a supine (lying down) position with the neck slightly extended (for internal jugular access) or in a slightly reclined position for subclavian vein access.
The insertion site is cleaned with an antiseptic solution, and sterile draping is applied to minimize the risk of infection.

Local Anesthesia:

Local anesthesia is administered at the insertion site to ensure the procedure is painless and comfortable for the patient.

Insertion of the Catheter:

The catheter is inserted into a central vein (usually the internal jugular vein, subclavian vein, or in some cases the femoral vein).
A guidewire is used to position the catheter correctly. The guidewire helps the physician navigate the catheter into the correct vein and position.

Tunneling Process:

A small subcutaneous tunnel is created beneath the skin to secure the catheter in place and reduce the chance of infection at the exit site.
The catheter is threaded through this tunnel to exit at a location near the chest wall, generally at the subclavian area or upper chest.

Securing the Catheter:

Once in position, the catheter is secured with sutures to prevent dislodgement. The insertion site is dressed with a sterile bandage to reduce infection risk.

Catheter Testing:

Blood flow and catheter patency are tested to ensure that the catheter is functioning correctly, with appropriate blood flow for dialysis.

Advantages of Tunneled Catheters/Permcaths

Long-term Use:

Tunneled catheters can be used for long-term dialysis access, providing stable access for patients who need chronic dialysis.

Reduced Infection Risk:

The tunneling mechanism reduces the risk of infection at the catheter insertion site, making it safer for prolonged use compared to regular non-tunneled catheters.

Improved Comfort:

The catheter’s design allows for greater patient mobility and comfort compared to non-tunneled catheters, which are more prone to dislodgement and discomfort.

Reduced External Exposure:

With the catheter tunneled under the skin, it’s less prone to accidental dislodgement or damage from external sources.

Potential Complications of Tunneled Catheter/Permcath Insertion

While tunneled catheters are generally safe, there are risks associated with the procedure, including:

Infection:

Despite reduced infection risk, catheter-related bloodstream infections (CRBSIs) are still possible. Proper catheter care and hygiene are essential to minimize this risk.

Thrombosis:

The formation of blood clots in the catheter or vein can lead to blockage, making dialysis more difficult.

Pneumothorax:

If the catheter is incorrectly inserted, it can puncture the lung, leading to a collapsed lung (pneumothorax).

Bleeding:

Although rare, bleeding can occur during the procedure, especially if blood vessels are injured.

Catheter Displacement:

If not properly secured, the catheter can become displaced, leading to malfunction or ineffective dialysis.

Care and Maintenance of Tunneled Catheters/Permcaths

Proper care and maintenance are crucial to ensure the longevity and functionality of the tunneled catheter. Key practices include:

Regular Flushing:

The catheter should be flushed with heparinized saline to prevent clot formation and ensure patency.

Exit Site Care:

The catheter’s exit site should be cleaned and inspected regularly for signs of infection, such as redness, swelling, or discharge.

Dressing Changes:

Sterile dressings should be applied to the exit site, with regular changes to reduce infection risk.

Monitoring for Complications:

Regular monitoring for signs of infection, thrombosis, or catheter displacement is essential.

Conclusion

Tunneled Catheter (Permcath) insertion provides a reliable, long-term solution for dialysis access, especially for patients with chronic kidney disease or those requiring emergency hemodialysis. Although the procedure is relatively safe, it requires careful monitoring and maintenance to minimize complications. If you or a loved one requires a tunneled catheter for dialysis, it’s important to consult with an experienced nephrologist or vascular specialist to ensure the best care and outcomes.