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Background and Objectives: Ultrasound-guided placement of tunneled hemodialysis catheters may be useful when fluoroscopy is unavailable or radiation exposure should be avoided. This study describes a technique based on direct ultrasound visualization of the metallic guidewire within the right atrium and evaluates one-year clinical and functional outcomes. Materials and Methods: We conducted a single-center retrospective observational study of 319 adult hemodialysis patients undergoing tunneled catheter placement. The technique combined intravascular guidewire length measurement with subcostal ultrasound visualization of the guidewire tip in the right atrium. Baseline characteristics, insertion site, immediate complications, blood flow rate, Kt/V, and extracorporeal circuit pressures were analyzed. Results: Mean age was 55.9 ± 14.5 years, and 58.6% were women. The main causes of chronic kidney disease were diabetes mellitus and arterial hypertension. Mean blood flow rate was 349 mL/min at 3 months and 357 mL/min at 12 months. Mean Kt/V at 12 months was 1.57. No catheter malpositions requiring immediate repositioning were documented. Procedure-related complications were infrequent and mainly local. Conclusions: Ultrasound-guided tunneled catheter placement using direct visualization of the guidewire within the right atrium was technically feasible and associated with favorable functional parameters and few immediate complications. Given the retrospective design and lack of a comparative group, these findings should be interpreted with caution. Prospective comparative studies are needed to confirm safety, reproducibility, and clinical utility.