Nursing Management of Hepatic Artery Infusion Pumps in Patients With Colorectal Liver Metastases

Abstract

BACKGROUND

More than half of patients with colorectal cancer will present with or develop colorectal liver metastases during the course of the disease. A hepatic artery infusion pump (HAIP) has been shown to improve patient outcomes and overall survival, even in previously unresectable tumors.

OBJECTIVES

Although much of the literature focuses on the pump itself, this article provides a guide to nursing considerations for patients with an HAIP, covering the trajectory of care from preoperative through postoperative settings and beyond.

METHODS

A review of the existing literature and knowledge gained from experience resulted in recommendations for nursing management throughout patients’ care.

FINDINGS

Recognizing both the common and unique elements of HAIP management can improve patient and nursing competence, normalizing care for these patients. Nurses familiar with HAIP management ensure continuity of care, can anticipate potential complications, and adapt care to meet each patient’s evolving needs across healthcare settings from presurgery to postchemotherapy, including educating the patient and family.

IN THE UNITED STATES, COLORECTAL CANCER (CRC) is the fourth most common cancer, with more than 150,000 new diagnoses each year, and the second leading cause of cancer-related deaths (National Cancer Institute Surveillance, Epidemiology, and End Results Program, 2025). More than half of patients with CRC will present with or develop colorectal liver metastases during the course of the disease (McFadden et al., 2022; Qadan & D’Angelica, 2015; Zeineddine et al., 2023). In the 1960s, hepatic artery infusion (HAI) chemotherapy emerged as a novel locoregional treatment targeting liver metastases (Almadrones et al., 1995; Parks & Routt, 2015). This therapy has been shown to improve patient outcomes and overall survival, even in previously unresectable tumors (D’Angelica et al., 2015; Kemeny et al., 2016; McFadden et al., 2022).

HAI is delivered through a HAI pump (HAIP), which can be used alone or, more commonly, in combination with systemic therapy as both neoadjuvant and adjuvant treatment. The pump delivers chemotherapy directly to the liver at concentrations as much as 400 times higher than systemic administration, providing localized tumor control with little to no systemic spillover and toxicity (Buisman et al., 2019). This method has been proven to be effective in reducing tumor burden (Chaudhry et al., 2021). Unfortunately, patients with cirrhosis, those with impaired liver function, those who are unable to tolerate major abdominal surgery, those with extrahepatic disease, or those with liver tumor volume greater than 70% may not be suitable candidates for HAI (McDonald et al., 2023).

The pump hardware has evolved over time, starting with a percutaneous model attached externally to the patient, and later becoming a surgically implanted device in the abdominal wall (Hagle, 2003). Despite its promise, the original manufacturer decided to discontinue the pump production, citing a scarcity of raw material in 2018 (Ellis et al., 2019). The HAIP returned to the market in 2021 after receiving approval from the U.S. Food and Drug Administration under a new manufacturer (McDonald et al., 2023). As of 2025, there is only one U.S. Food and Drug Administration–approved HAIP. The Intera 3000 HAIP, a magnetic resonance imaging–compatible two-chamber pump made of titanium, is available internationally (see Figure 1). It features a constant-flow system with one chamber containing a propellant that expands with body heat, compressing the second chamber, a collapsible drug reservoir (Martin, 2002). The pump is cylindrical, about 3 inches in diameter and 1 inch deep, and weighs less than 0.5 pounds, or about the size of a hockey puck (Martin, 2002; Parks & De Villiers, 2022).

FIGURE 1.

ILLUSTRATION OF PUMP AND REFILL PROCEDURE

©2024 Intera Oncology. All rights reserved. Used with permission of Intera Oncology.

Caring for patients with an HAIP requires a dedicated interprofessional team, including nurses, surgeons, oncologists, and pharmacists. The National Comprehensive Cancer Network recommends that locoregional therapies, like HAI, be performed at institutions with surgical and medical oncology expertise (National Comprehensive Cancer Network, 2025). In addition, in 2020, the international HAI Consortium Research Network was formed to further expertise in the locoregional intervention (Judge et al., 2023). Nurses provide support to patients with an HAIP throughout the care continuum, requiring a deep understanding of the technical and patient care aspects, given the complexity of HAIP placement and the potential for complications (McDonald et al., 2023).

Although much of the literature focuses on the pump itself, this article provides a guide to nursing considerations for HAI with an HAIP, covering the trajectory of care from preoperative through postoperative settings.

Preoperative Setting

Preoperative assessment for a patient being considered for HAIP placement includes a detailed history, a physical examination, laboratory studies, and high-resolution cross-sectional imaging, such as computed tomography with angiography and liver-sequenced magnetic resonance imaging. This comprehensive workup helps determine the patient’s readiness for surgery and suitability for HAI therapy. Nurses ensure that the patient understands the procedure, including its risks and benefits, as with other patients undergoing surgery. They assess the patient’s baseline knowledge and provide educational materials tailored to the patient’s literacy level, covering the purpose of the HAIP, potential complications, and postoperative expectations and care.

Because the pump may remain in place for years, patients will need to return to the clinic for pump filling every 2–12 weeks for the duration of its use to prevent the pump from running dry (Intera Oncology, 2025; McDonald et al., 2023; Parks & De Villiers, 2022). Nurses assess the patient’s family support and potential barriers to adhering to this follow-up schedule, as consistent visits are critical to treatment success. Patients and their caregivers must fully commit to the treatment and understand the risks of missed or delayed appointments (Chaudhry et al., 2021; Parks & De Villiers, 2022). In addition, nurses provide emotional support, address anxiety, and engage the family in the care process. This is particularly important given the nature of the procedure and the psychological difficulty of a metastatic cancer diagnosis.

Intraoperative and Postanesthesia Recovery Setting

Implanting an HAIP—whether done alone or as part of a colon, rectum, or liver resection—is a highly specialized procedure. Understanding the steps involved helps nurses anticipate and prevent complications. The hepatic surgeon implants the pump through either open or minimally invasive (laparoscopic or robotic) surgery (Qadan et al., 2017). Patients receive prophylactic antibiotics prior to skin incision. Preoperative marking assists with placement around bony prominences and any diverted bowel.

During surgery, the hepatic tree, which includes the hepatic artery, proper hepatic artery, and gastroduodenal artery, is dissected and the catheter is typically placed in the gastroduodenal artery and then connected to the pump, which is sutured into a subcutaneous pocket, usually in the lower abdomen (Parks & De Villiers, 2022; Qadan et al., 2017) (see Figure 2). A prophylactic cholecystectomy is performed to prevent chemotherapy-induced cholecystitis (Parks & De Villiers, 2022; Qadan et al., 2017). The surgeon ligates distal vessels and any accessory or replaced vessels to avoid extrahepatic perfusion or nonperfusion (Barber & Fabugais-Nazario, 2003; Hagle, 2003; Parks & Routt, 2015). A methylene blue or fluorescein dye study with a Wood’s lamp (an ultraviolet light used to detect fluorescence) is performed to confirm proper liver perfusion and the absence of extrahepatic perfusion (Martin, 2002; Qadan et al., 2017). Patients often report changes to urine color as a result of fluorescein or blue dye, and nurses can educate patients that this is expected. Before completing the surgery, a local analgesic is injected into the abdominal wall, and the pump is primed and filled with heparinized saline (Qadan et al., 2017). All wounds are meticulously closed in multiple layers to eliminate dead space and prevent superficial site infections.

FIGURE 2.

ILLUSTRATION OF A HEPATIC ARTERY INFUSION PUMP PLACEMENT

Note. Artist, Jana Zeineddine, rendering. Used with permission of M. Qadan, owner.

Intraoperatively, the nurse continues to advocate for and support the patient. The education provided to the patient and family during the preoperative phase forms the foundation for care during the surgery (Chellam Singh & Arulappan, 2023). The nurse ensures patient safety throughout the procedure by conducting safety checks and verifying that all necessary materials and equipment are available and ready (Chellam Singh & Arulappan, 2023).

Postoperative care in the postanesthesia care unit is similar to that for other patients undergoing surgery. The nurse monitors vital signs, assesses the surgical dressing for signs of bleeding, and evaluates the patient’s neurologic status. After excluding potential postoperative shock, care focuses on ensuring adequate pain control and evaluating fluid volume status. Throughout the operative phase, the nurse maintains communication and empathy, building rapport with the patient and family while continuing to advocate for the patient’s well-being (Chellam Singh & Arulappan, 2023).

Acute Care Postoperative Setting

Nursing management during the immediate inpatient postoperative period is critical to the successful use of an HAIP as a treatment modality. As with other surgeries, the patient’s length of stay is associated with the extent of the surgery and the surgical approach (Qadan et al., 2017), typically ranging from two to six days (Memorial Sloan Kettering Cancer Center, 2023; Qadan et al., 2017; Ten Haaft et al., 2024). Postsurgical complications are similar to those seen in other patients, including infection, seroma, and bleeding (Italiano, 2018; Parks & De Villiers, 2022). Additional complications, such as vascular complications related to catheter placement, extrahepatic perfusion, and nonusability of the pump, may less commonly manifest during acute postoperative admission (see Table 1) (Italiano, 2018; Parks & De Villiers, 2022). There are also complications unique to the pump placement that the surgical team can address, including pump inversion, or when the pump rotates, making the septum inaccessible to fill the fluid chamber (Italiano, 2018; Parks & De Villiers, 2022).

TABLE 1.

POSTSURGICAL COMPLICATIONS OF A HEPATIC ARTERY INFUSION PUMP

COMPLICATION	PRESENTATION	ASSESSMENT	INTERVENTION/PREVENTION	SOURCES
Bleeding	■ Increase in sanguineous dressing saturation	■ Regular assessment of dressing (every 4 hours)	■ Notify responding clinician. ■ Avoid subcutaneous injection in the abdomen to allow for monitoring. ■ Embolization	Barnett & Malafa, 2001; Hagle, 2003; Martin, 2002; Parks & De Villiers, 2022
Infection	■ Erythema ■ Tenderness ■ Drainage ■ Fever	■ Laboratory values ■ Surgical site visualization ■ Vital signs	■ Notify responding clinician. ■ Oral antibiotics ■ IV antibiotics ■ Removal of device	Barnett & Malafa, 2001; Hagle, 2003; Italiano, 2018; Martin, 2002; Parks & De Villiers, 2022
Necrosis	■ Redness ■ Pain ■ Skin breakdown	■ Assessment of skin above hepatic artery infusion pump	■ Notify responding clinician. ■ Maintain patient weight.	Barnett & Malafa, 2001; Martin, 2002
Pump inversion	■ Difficulty palpating septum	■ Abdominal x-ray for confirmation	■ Notify responding clinician. ■ Abdominal binder ■ Avoid heavy lifting and some forms of exercise.	Italiano, 2018; Martin, 2002; Parks & De Villiers, 2022; Parks & Routt, 2015
Seroma	■ Collection of fluid in pump pocket	■ Difficult to palpate/access pump septum	■ Notify responding clinician. ■ Abdominal binder ■ Fluid aspiration ■ Diuretics ■ Maintain patient weight.	Barnett & Malafa, 2001; Italiano, 2018; Martin, 2002; Parks & De Villiers, 2022

Nurses support patient recovery assessment and management, including monitoring for bleeding, which is a common surgical risk that is compounded by the use of heparinized saline in the pump and requires pharmacologic prophylaxis to prevent deep vein thrombosis. Regular assessment of the primary dressing helps the nurse identify early signs of bleeding complications. Nurses can administer subcutaneous injections in the arm instead of the abdomen to prevent bruising that could mask signs of pump-related bleeding. Although hot packs and heating pads are used for multimodal postoperative pain, they could raise the temperature in the abdominal wall and increase the pump’s flow rate in patients with an HAIP and, therefore, should be avoided (Intera Oncology, 2025).

Other potential complications include seromas, or fluid collections in the pump pocket, which are usually self-limiting and can be managed with compression bandaging or observation (Italiano, 2018). An abdominal binder can help prevent fluid reaccumulation and reduce the risk of pump inversion (Italiano, 2018). Nurses also provide education to patients and their families, triaging concerns in the postoperative period before the patient is discharged home. Nurses ensure that caregivers understand how to manage recovery and when to seek help. After discharge, patients are encouraged to contact the outpatient clinic with any concerns. Finally, because an HAIP may trigger metal detectors, patients receive an identification card from the manufacturer at discharge for use at security screenings. Patients are also educated about traveling with the pump, as air travel is permitted in pressurized cabins (Italiano, 2018).

Chemotherapy Administration Setting

The purpose of the pump is to administer targeted locoregional chemotherapy. After implantation but prior to initiation of chemotherapy, a formal perfusion study is completed to rule out extrahepatic perfusion and ensure bilobar hepatic perfusion. The scan is typically performed predischarge during the index hospitalization or shortly following discharge within the first two weeks by a trained nurse and a nuclear medicine technologist. There is appreciable swelling at the pump site in the first few days postoperation, which is typically when the nuclear medicine scan is performed. This can result in increased difficulty in accessing the pump. Patients also tend to have increased anxiety and pain with palpation and needle insertion at this time point. Therefore, the nurse facilitates collaboration with the inpatient team to ensure adequate pain control and determine whether an anxiolytic is needed prior to the nuclear medicine scan and procedure.

During the chemotherapy phase, the patient returns every two weeks to an outpatient clinic to have the pump reservoir refilled with chemotherapy by specially trained chemotherapy nurses (McDonald et al., 2023). The National Comprehensive Cancer Network (2025) recommends floxuridine as the chemotherapeutic agent because of its high first-pass metabolism in the liver. The nurse assesses the site for potential complications prior to accessing the pump at each visit and alerts the surgeon and medical oncologist if there are any concerns before proceeding. The pump is cycled between a continuous chemotherapy infusion for two weeks and a heparinized saline infusion alone for two weeks, for at least six cycles (Parks & De Villiers, 2022). During this phase, some patients receive systemic chemotherapy along with the locoregional therapy (Rao et al., 2024). Treatment for unresectable disease typically occurs for three to six months to allow for sufficient therapy to be administered to convert to resectability.

While the pump is actively cycling, patients are at increased risk for pump-related complications, in addition to postsurgical complications (see Table 2). Every two weeks, the nurse accesses the pump, withdraws the remaining fluid in the chamber, and calculates an individual flow rate by dividing the residual volume of the chemotherapy agent or heparinized saline by the number of days since the pump was previously accessed (e.g., the residual rate = 15 ml, after 14 days, 15/14 = 1.07 ml flow rate). A flow rate outside of what is expected may indicate to the nurse a “dry” HAIP when there is no remaining fluid in the pump, or a thrombosis when there is too much fluid in the pump. A dry HAIP increases the risk of occlusion, which can jeopardize the pump’s ability to be used, and is typically associated with a delayed return-to-fill appointment, fevers and other heat exposures like saunas, or travel to high altitudes (Barber & Fabugais-Nazario, 2003; Italiano, 2018; Parks & De Villiers, 2022).

TABLE 2.

CHEMOTHERAPY COMPLICATIONS WITH HAIP

COMPLICATION	PRESENTATION	ASSESSMENT	INTERVENTION/PREVENTION	SOURCES
Chemical hepatitis/biliary sclerosis	■ Elevated liver function tests ■ Right upper quadrant pain	■ Monitor liver function tests. ■ Calculate HAIP individual flow rate regularly.	■ Notify responding clinician. ■ Modify chemotherapy regimen. ■ Use of ursodiol ■ Use of dexamethasone	Italiano, 2018; Martin, 2002; Parks & De Villiers, 2022
Dry HAIP	■ No residual volume in the chamber	■ Vital signs ■ Calculate HAIP individual flow rate regularly.	■ Notify responding clinician. ■ Report fever, travel to high altitudes, and high blood pressure. ■ Avoid saunas, hot tubs, and exposure to extreme temperatures, including heating pads or packs.	Hagle, 2003; Martin, 2002; Parks & De Villiers, 2022; Parks & Routt, 2015
Gastrointestinal ulcer	■ Abdominal pain, dark or tarry stools	■ Monitor patient for abdominal pain and dark/tarry stool.	■ Notify responding clinician. ■ Proton pump inhibitors	Italiano, 2018; Martin, 2002; Parks & De Villiers, 2022
Hepatic artery thrombosis	■ Excess residual volume in the chamber	■ Calculate HAIP individual flow rate regularly.	■ Notify responding clinician. ■ Continuous infusion of chemotherapy, saline/heparin, or glycerin	Martin, 2002

HAIP—hepatic artery infusion pump

If the flow rate is within the range of what is expected for that patient, the nurse attempts to flush the pump, following institutional policy and procedures. If the flush is successful, the pump chamber is refilled and monitored. When the residual volume is high and the flow rate is low, the nurse follows institutional policy in informing the advanced practice nurse or physician before attempting to flush the pump using a designated bolus pathway (Intera Oncology, 2025). If resistance is met, the nurse aborts the flushing procedure and again follows institutional policy, informing the covering advanced practice nurse or physician. For pumps with resistance, imaging can be done to assess the cause, and alteplase can be instilled through the bolus pathway to attempt to restore patency of the catheter (Italiano, 2018).

Nurses ensure patients’ appointments are scheduled at appropriate intervals for their pump refills. The nurse also provides ongoing patient education to emphasize the importance of keeping all scheduled appointments and notifying the team of unavoidable temperature fluctuations, such as fevers, as well as travel plans where altitude could affect the flow rate.

Nurses assess and manage the side effects of floxuridine, a weight-based chemotherapeutic, including complications related to the toxicity of the chemotherapy agent—most notably, biliary sclerosis, which is a serious and potentially irreversible complication in advanced stages and results from direct toxicity to the biliary tree, particularly when combined with systemic therapy (Rao et al., 2024). Surveillance includes liver function tests performed every two weeks. Medications like proton pump inhibitors help prevent gastric ulcers and are routinely administered to all patients with an HAIP on an indefinite basis (Cozzi et al., 1984; Parks & De Villiers, 2022; Parks & Routt, 2015). Dexamethasone is typically added to the patient’s treatment plan to avoid chemical hepatitis and minimize the incidence of biliary sclerosis (Cozzi et al., 1984; Parks & De Villiers, 2022; Parks & Routt, 2015). Nurses educate patients about expected and unexpected signs and symptoms with HAI therapy, including jaundice and extrahepatic perfusion resulting in severe gastric mucositis symptoms, like abdominal pain and nausea (Barnett & Malafa, 2001). They also educate patients about the use of ursodiol, which prevents gallstone formation and mitigates biliary toxicity (Parks & De Villiers, 2022).

Accessing the HAIP every two weeks may involve mild discomfort because of the needlestick. The nurse may apply lidocaine–prilocaine cream to the pump area about 30 minutes prior to accessing the pump to minimize patient discomfort. The nurse uses a 22-gauge, straight, noncoring, 1- or 2-inch needle provided by the manufacturer to access the pump (Intera Oncology, 2025). In patients with a larger volume of subcutaneous fat, or in patients with a pump that is implanted deeper into the soft tissue, a larger needle is used to access the pump.

Postchemotherapy Administration Setting

After chemotherapy, the pump remains in place. Instead of instilling a chemotherapy agent or heparinized saline, post-treatment, a sterile solution of glycerin and saline fluid can be used as a long-term locking agent to fill the chamber. Because glycerin has a slower flow rate, patients do not need to return as frequently for pump access, typically returning every 6–12 weeks, depending on the institutional policy (Intera Oncology, 2025; Parks & Routt, 2015). The pump can safely remain in place for years and can be removed if the patient remains disease-free for five years and is considered cured. For patients who choose to have the pump removed, the pump cannot be reimplanted, as removal generally involves extracting the abdominal wall port rather than the abdominal arterial catheter. If a patient nears the end of life and is no longer pursuing treatment with the pump still in place, they or their care team may choose to let the pump run dry without concern (Italiano, 2018).

Patients with symptomatic liver failure as a result of hepatic tumor burden often develop symptomatic ascites. Indwelling peritoneal catheters can be used to drain fluid painlessly. However, the indwelling catheters increase the risk of peritonitis and HAIP infections. In this circumstance, nurses work with the treating team to identify patients who would benefit from using prophylactic antibiotics.

Implications for Nursing

Patients with an HAIP have unique clinical considerations spanning surgical recovery, device management, and chemotherapy delivery. A thorough understanding of HAIP functionality enables nurses to anticipate and mitigate complications, such as bleeding, infection, and altered pump performance, particularly during the critical postoperative period and across chemotherapy cycles. Oncology nurses provide patient and caregiver education, reinforcing procedural comprehension; identify early signs of adverse events; and coordinate interprofessional care. By integrating evidence-based knowledge into practice, nurses enhance safety, support patient autonomy, and promote transitions throughout the continuum of cancer treatment. As HAIP therapy prevalence increases, nursing expertise ensures high-quality, consistent care aligned with evolving oncology standards.

Conclusion

The HAIP represents an important therapeutic modality for patients with colorectal liver metastases, offering the potential to slow disease progression and extend survival. Although the technology emerged decades ago, its broader adoption has historically been hindered by clinical complexity and limited nursing engagement. A thorough understanding of the pump’s mechanism and anticipation of patient care requirements increase nursing confidence across settings from presurgery to postchemotherapy. Although some aspects of HAIP care parallel general postoperative management, others require specialized knowledge and vigilance. Nurses trained in HAIP therapy ensure continuity, anticipate complications, and individualize care, thereby supporting optimal outcomes. As adoption expands, embedding HAIP expertise within nursing practice not only strengthens interprofessional collaboration but also elevates the standard of care for this growing patient population.

IMPLICATIONS FOR PRACTICE.

• ■Use hepatic artery infusion chemotherapy to improve patient outcomes and overall survival, even in previously unresectable tumors in patients with colorectal liver metastases.

• ■Educate patients with a hepatic artery infusion pump and their families about activities that may affect the viability of their pump.

• ■Monitor for complications related to the pump.