What is the preferred type of dialysis catheter, tunneled (permanent) or temporary, for patients requiring long-term dialysis?

Tunneled Catheters vs Temporary Catheters for Long-Term Dialysis

For patients requiring long-term hemodialysis, tunneled cuffed catheters are strongly preferred over temporary catheters due to significantly lower mortality, infection rates, and better patency rates. 1, 2

Catheter Selection Algorithm

1. First-line access: Arteriovenous fistula (AVF) or arteriovenous graft (AVG)

   • Associated with lowest mortality (29.5% for AVF vs 42.2% for catheters)
   • Lowest infection rates
   • Best long-term patency

2. When AVF/AVG not immediately usable:

   • Use tunneled cuffed catheter as bridge to permanent access
   • Temporary catheters should be avoided for periods >7 days

3. Indications for long-term tunneled catheter use:

   • Multiple prior failed AV accesses with no feasible options
   • Noncorrectable central venous outflow occlusion
   • Severe arterial occlusive disease
   • Patient preference after informed consent
   • Limited life expectancy
   • Pediatric patients with prohibitively small vessels

Evidence Supporting Tunneled Catheters

The 2023 KDOQI guidelines clearly state that tunneled catheters are appropriate for short-term use when an AVF or AVG is maturing but dialysis is required 1. The evidence strongly demonstrates that temporary catheters are associated with:

• 51% increase in mortality (aHR 1.51)
• 69% decrease in primary patency (aHR 0.31)
• 130% increase in severe infection (aHR 2.3) 1

Mortality is 2.2 times higher for patients using hemodialysis catheters compared to those with AVFs (aHR 2.25) 1. The absolute all-cause mortality rates are striking:

• AVF: 29.5%
• AVG: 36.7%
• Catheter: 42.2% 1

Catheter Placement Considerations

When a tunneled catheter is required, the preferred insertion sites in order of preference are:

1. Right internal jugular vein (most direct route to right atrium)
2. Left internal jugular vein
3. External jugular vein
4. Femoral vein
5. Subclavian vein (last resort due to stenosis risk) 2

Complications and Management

Tunneled catheters, while better than temporary catheters, still carry significant risks:

• Catheter-related bloodstream infections (CRBSI): 3.74 episodes per 1000 catheter-days 3
• Central venous stenosis (33.4% of long-term users) 4
• Catheter displacement (27.8%) 4
• Thrombosis (7.9%) 4

Nearly half (47.6%) of patients with long-term tunneled catheters require catheter exchange during the prolonged use period 4.

Special Considerations

For patients already using a temporary catheter who need long-term access, converting the temporary catheter to a tunneled catheter using the same venous insertion site is safe and preserves future access sites. This approach has shown:

• 100% technical success rate
• 72% patency at 30 days
• No increased infection risk compared to de novo placement 5

Ethical Considerations

There is an ethical obligation to avoid long-term catheter use when an AVF or AVG is possible, given the significantly higher mortality and complication rates. Catheters should be presented to patients as temporary measures that are unsafe for long-term use 6.

Key Pitfalls to Avoid

1. Using temporary catheters beyond 7 days when tunneled options are available
2. Failing to plan for permanent access creation while using a catheter
3. Placing catheters in the subclavian vein, which can lead to central venous stenosis
4. Not monitoring for signs of infection or dysfunction
5. Presenting catheters as equivalent alternatives to AVF/AVG