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HAI pump injection protocol

Hepatic arterial infusion (HAI) pump perfusion scintigraphy

Purpose: to confirm bilobar distribution from the pump catheter tip and lack of extrahepatic perfusion (exactly as we do for Y90 phase 1 planning). Typically performed 2-4 days after pump implantation, when not able to be performed blindly by surgical oncology team

Note: The currently utilized HAI pump for the past few years is the Codman Intera pump. The previously used pump was the Medtronic pump, but some patients still have it. All of the current pump injections will be Intera.

TECH SETUP

  • Supplies needed: one SPECIALIZED Intera bolus needle OR a Medtronic needle (absolutely NO other needle is compatible with these pump), cup containing 20mL of heparinized saline (100 u/mL) (OK to squirt the pre-mixed low dose heparinized saline syringes int cup)
  • 10mL syringe
  • Prep: Chlorhexidine to abdomen pump site, and prep with blue towels (full draped not needed)
  • The Intera Non-Coring (Huber) Special Bolus Needle comes in 1 3/8″ or 2″.
  • The Medtronic Catheter Access Port Kit comes with a 1.5” and a 2” needle

PROCEDURE STEPS:

  • STEP 1: Determine which kind of pump the patient has

 

  • *** Inform tech which needle brand is needed. They are completely different and NOT interchangeable.
  • For obese patients use the 2” needle. For non-obese, use the 1 3/8 or 1.5” needle for Intera and Medtronic, respectively

 

Intera Pump instructions:

  • Note from the pump diagram below that the needle infuses liquid via a slot in the middle of the needle shaft instead of the tip.
  • Using sterile gloves, connect the specialized needle tubing to a 3-way stopcock and prime the needle and tubing with heparinized saline (100u/mL).
  • Using fluoroscopic triangulation, insert the specialized Intera bolus needle into the CENTER of the pump (see example fluoro image below). Advance the needle until it definitely hits the back wall firmly. It is a deep chamber (see diagram), and you will feel more resistance than inserting through a regular port diaphragm, because it is a longer distance. Advance until you feel it very definitely hitting metal. Or else you will inject it subcutaneous.
  • Do not aspirate blood.
  • Inject 5mL of the heparinized saline – should have mild resistance to flow if correctly in place.
  • Hook the 10mL syringe on the back of a 3-way stopcock. With the stopcock arm pointed towards the middle hub, prime forward, and make a good wet to wet connection to the needle tubing. Then point the stopcock arm towards the needle tubing, and prime some saline up so that the nuclear medicine tech can make a good wet to wet connection. The tech should aspirate 1mL of saline to get rid of the hub bubble. Then turn the stopcock towards your 10mL syringe, and the tech should slowly inject the Tc99-MAA into the pump at a rate of 1mL per minute. Then they should aspirate 2mL of saline from your syringe via the stopcock, and repeat. Do one final rinse, then inject the rest of the heparinized saline.
  • Remove needle and discard per radiation safety precautions along with gloves into the radiation container
  • NEVER aspirate blood – can predispose to pump occlusion
  • If you have resistance to injection, it may not be firmly against the back wall of the pump. Make sure it is central and perpendicular within the middle. Use fluoroscopy to check for kinks within the pump catheter
  • If you need to perform a pump interrogation with contrast, you can inject with contrast (DSA).

Medtronic Pump Instructions

  • The pump needle is more like a small gauge huber needle. Note from the pump diagram above that the needle access port is a tiny target in the corner of the pump
  • Using sterile gloves, connect the specialized needle tubing to a 3-way stopcock and prime the needle and tubing with heparinized saline (100u/mL).
  • Using fluoroscopic triangulation, insert the specialized Medtronic needle into the small corner target. Advance the needle until it definitely hits the back wall firmly.
  • Aspirate blood to confirm you are in it. (only with the Medtronic pump)
  • Inject 5mL of the heparinized saline – should have mild resistance to flow if correctly in place.
  • Hook the 10mL syringe on the back of a 3-way stopcock. With the stopcock arm pointed towards the middle hub, prime forward, and make a good wet to wet connection to the needle tubing. Then point the stopcock arm towards the needle tubing, and prime some saline up so that the nuclear medicine tech can make a good wet to wet connection. The tech should aspirate 1mL of saline to get rid of the hub bubble. Then turn the stopcock towards your 10mL syringe, and the tech should slowly inject the Tc99-MAA into the pump at a rate of 1mL per minute. Then they should aspirate 2mL of saline from your syringe via the stopcock, and repeat. Do one final rinse, then inject the rest of the heparinized saline.
  • Remove needle and discard per radiation safety precautions along with gloves into the radiation container
  • If you have resistance to injection, it may not be firmly against the back wall of the pump. Make sure it is central and perpendicular within the middle. Use fluoroscopy to check for kinks within the pump catheter

 

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