Background and Objectives: Tunneled hemodialysis catheters (TDCs) are essential for vascular access in patients with end-stage renal disease (ESRD). This study retrospectively evaluated the clinical outcomes of permanent TDCs placed at a single center, comparing heparin-coated versus non-heparin-coated catheters. Materials and Methods: A total of 189 patients who underwent permanent TDC placement between January 2021 and January 2022 were included. Patients were categorized by catheter type (heparin-coated, n = 80; non-heparin-coated, n = 109). Catheter failure-free survival was analyzed using the Kaplan–Meier method, with arteriovenous fistula creation treated strictly as a censoring event. Multivariable Cox proportional hazards regression was used to identify independent predictors of catheter failure. Results: Complications were significantly more frequent in the non-heparin-coated group (p = 0.004). Catheter exchange was required exclusively in the non-heparin-coated group (p < 0.001). Kaplan–Meier analysis demonstrated significantly longer failure-free catheter survival in the heparin-coated group (restricted mean 49.0 vs. 41.7 months; Log-Rank p < 0.001). On multivariable Cox regression, the complete absence of events in the heparin-coated group yielded a strong protective point estimate (HR = 0.087, 95% CI: 0.004–1.710), rendering individual patient covariates such as INR and age non-significant. Conclusions: Heparin-coated TDCs were associated with significantly longer failure-free survival and lower complication rates compared with non-heparin-coated catheters. Due to the low overall event rate, individual patient-level covariates including INR did not reach statistical significance in the multivariable model.