Tunneled Central Venous Catheters: Hickman, Broviac, and Groshong Clinical Guide
Clinical guide to tunneled central venous catheters: Hickman, Broviac, and Groshong types, indications, care and maintenance, flushing protocols, complication management, and comparison with implanted ports.
Tunneled Central Venous Catheters: Hickman, Broviac, and Groshong Clinical Guide
Tunneled central venous catheters (CVCs) are surgically placed long-term central access devices designed for dwell times of months to years. The subcutaneous tunnel separates the skin exit site from the venous entry point, providing a physical infection barrier and mechanical stability. Tunneled CVCs are the preferred long-term central access device when an implanted port is not feasible or when external access is required for frequent (daily or near-daily) use.
Parent guide: Central Venous Catheters: Complete Clinical Reference
What Is a Tunneled CVC?
A tunneled CVC consists of a central venous catheter whose proximal end is passed subcutaneously from the venous entry site (typically the IJ or subclavian vein) to a separate skin exit site on the chest wall or upper abdomen. A Dacron polyester cuff positioned along the subcutaneous tunnel segment promotes fibrous tissue ingrowth (fibroplasia), anchoring the catheter and creating a biological infection barrier between the skin exit site and the bloodstream.
Key anatomic features:
- Venous entry site: IJ, subclavian, or femoral vein (upper body preferred)
- Subcutaneous tunnel: Creates physical separation between exit site and vein entry; typically 5–10 cm
- Dacron cuff: 1–2 cuffs; positioned in the tunnel; tissue ingrowth occurs over 2–4 weeks post-insertion
- Skin exit site: Where the catheter emerges; site of routine exit-site care
- External catheter: One or more external lumens with hubs and clamps
Types of Tunneled CVCs
Hickman Catheter
The classic open-ended tunneled CVC. Available in single, double, and triple lumen configurations, and in various Fr sizes (6.6 Fr to 14 Fr). Features a clamp on each external lumen.
Use: Home TPN, long-term IV antibiotics, stem cell transplantation, chronic home IV therapy.
Flushing: Heparin lock (100 units/mL) required to maintain patency because the open-ended tip allows blood reflux into the lumen when the clamp is opened.
Broviac Catheter
Smaller-diameter version of the Hickman, designed for pediatric patients or adults requiring lower-flow access. Single lumen; available in very small Fr sizes (2.7 Fr) for neonates.
Use: Pediatric TPN, pediatric oncology access, smaller adult patients.
Flushing: Same as Hickman; heparin lock required.
Groshong Catheter
Differentiating feature: a pressure-sensitive three-position valve at the catheter tip. The valve remains closed at rest (neutral pressure), opens inward during blood withdrawal, and opens outward during infusion. This eliminates the need for heparin locking (saline lock is adequate) and eliminates the risk of air embolism through the catheter tip.
Use: Patients with heparin allergy or HIT; patients for whom heparin lock is contraindicated; home TPN and chronic access.
Flushing: Saline only — heparin lock is NOT used with Groshong valved catheters (heparin does not interact with the valve mechanism and provides no benefit).
Comparison note: Groshong valves may have slightly higher occlusion rates in high-viscosity lipid-based PN; open-ended Hickman design may be preferred for high-flow or lipid-heavy PN.
Indications
Tunneled CVCs are appropriate when:
- Long-term home IV therapy: Home TPN (months to years), chronic home IV antibiotics, long-term fluid/medication dependence
- Stem cell transplantation: High-intensity chemotherapy, engraftment support, frequent blood draws, and transfusion requirements over weeks to months
- Daily or near-daily IV access: When port access requires needle placement at every use, tunneled catheter eliminates this step for patients with high-frequency access needs
- Port is not feasible: Thrombocytopenia (platelet count too low for safe port implantation), previous failed port placements, patient preference for external access
- Pediatric long-term access: Smaller devices available for pediatric sizes
Tunneled CVC vs. port: For patients with chronic but intermittent IV access needs (weekly chemotherapy, monthly infusions), the implanted port is generally preferred — it has no external component, lower infection rate per dwell-day, and allows normal daily activity including swimming. The tunneled catheter is preferred for daily access needs where port needle access every day creates patient burden.
Placement Procedure
Tunneled CVCs are placed by interventional radiology (IR) or surgery under fluoroscopic guidance. The procedure:
- Venous access established at IJ or subclavian vein using standard Seldinger technique under US and fluoroscopy
- Tunneling device passed subcutaneously from chest exit site to venous entry site
- Catheter threaded through the tunnel
- Catheter advanced into SVC; tip positioned at CAJ under fluoroscopic guidance
- Catheter secured; exit site dressed
Post-procedure: Fluoroscopic tip confirmation is performed during placement. Post-procedure CXR may also be obtained per institutional protocol.
Exit Site Care
The exit site is the primary infection entry point for tunneled CVCs. Exit-site care is the most critical maintenance activity.
Frequency
- During the first 2–4 weeks post-insertion (pre-cuff fibrosis): daily exit-site care with sterile dressing
- Once cuff is fibrosed and site is healed: per institutional policy, typically weekly (some patients with well-healed exit sites and low-risk daily access use less frequent formal exit-site care)
Technique
- Don sterile gloves; clean exit site with CHG-based antiseptic
- Inspect exit site: erythema, swelling, tenderness, drainage (quantity, color, character)
- Inspect tunnel tract (palpate subcutaneously): tenderness, erythema, warmth along tunnel suggest tunnel infection
- Apply new sterile dressing; secure catheter to prevent tension on exit site
- Document findings
Exit Site Infection vs. Tunnel Infection
Exit site infection: Localized to the skin exit site (erythema, tenderness, purulent drainage limited to the exit site). May be treated with topical antiseptics or antibiotics; catheter salvage often possible.
Tunnel infection: Erythema, warmth, or tenderness extending along the subcutaneous tunnel tract. Represents infection tracking along the catheter path — much higher risk of CLABSI. Tunnel infection generally requires catheter removal.
Flushing and Locking
| Catheter Type | Lock Solution | Frequency |
|---|---|---|
| Hickman (open-ended) | Heparin 100 units/mL, 3 mL per lumen | After each use; daily if not in use |
| Broviac (open-ended) | Heparin 100 units/mL, 2 mL (smaller lumens) | After each use |
| Groshong (valved) | Normal saline, 5 mL per lumen | After each use; weekly if not in use |
| All types | Normal saline 10 mL pulsatile flush before lock | Before each lock |
Per institutional policy; confirm specific heparin concentration with pharmacy.
Complications
CLABSI
Tunneled CVCs have lower CLABSI rates than non-tunneled CVCs for comparable dwell times — the subcutaneous tunnel and Dacron cuff reduce intraluminal and extraluminal infection routes. However, CLABSI remains a significant risk, particularly for:
- Patients receiving immunosuppressive therapy
- High-access-frequency patients (daily use)
- TPN patients
Prevention: same bundle principles as other CVADs — scrub-the-hub, CHG exit-site care, daily necessity assessment (though tunneled CVCs are usually placed for defined long-term indications).
Catheter Occlusion
Managed per the same alteplase protocol as PICCs (2 mg/2 mL, 30-minute dwell). Groshong valved catheters have an additional troubleshooting step: confirm the valve is not externally compressed or kinked before concluding occlusion is thrombotic.
Cuff Extrusion
The Dacron cuff may occasionally migrate outward and become palpable or visible at the exit site. Cuff extrusion reduces the infection barrier and mechanical security of the catheter. Requires provider assessment — may require catheter replacement.
Accidental Dislodgement
Tunneled CVCs are more resistant to accidental removal than non-tunneled CVCs (due to tissue ingrowth at cuff), but dislodgement is still possible. If catheter is partially displaced (external length increased, cuff palpable near exit site), notify provider immediately — do not attempt to advance back.
Removal
Tunneled CVC removal is a surgical procedure because the Dacron cuff must be freed from surrounding fibrous tissue before the catheter can be removed. Removal is performed by IR or surgery under local anesthesia:
- Small incision over cuff site
- Blunt dissection to free the cuff from the fibrous ingrowth
- Catheter withdrawn from the venous system
- Exit site and cuff incision closed
This is not a bedside nursing procedure. Do not attempt to remove a tunneled CVC by simple traction — the cuff resistance can cause catheter fracture and embolism.
Related Resources
Related guides:
Related policies:
References
- Gorski LA, et al. (2021). INS Infusion Therapy Standards of Practice. J Infus Nurs, 44(Suppl 1).
- Bishop L, et al. (2007). Guidelines on the insertion and management of CVCs in adults. Int J Lab Hematol, 29(4):261–278.
- O’Grady NP, et al. (2011). CDC Guidelines for Prevention of Intravascular Catheter-Related Infections. MMWR, 60(RR-1).
- Vescia S, et al. (2008). Management of venous port systems in oncology. Ann Oncol, 19(1):9–15.