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Embolization is performed in the hospital, usually by a specially trained doctor called an Interventional Radiologist. Depending on the type of embolization procedure you have, you may need to stay overnight in the hospital, or you might be able to go home the same day.

The Procedure:

Before the procedure begins, you will have an intravenous placed to give you medications. In the procedure room, you will lay on the procedure table and a nurse will set up monitors to measure your blood pressure, heart rate and oxygen levels. The doctor will go over the procedure and its potential risks and benefits.

The procedure will begin with you receiving sedation through your intravenous to make you more relaxed. You may also be given antibiotics. In some cases you may be given general anesthesia. The doctor will then make a small cut in your upper leg. Through this cut, a thin flexible tube (called a catheter) will be placed inside a blood vessel in your leg. In some cases, this catheter might be inserted through a blood vessel in your wrist instead.

The doctor will guide the catheter through the blood vessel… until it reaches your liver…and then guide it to the tumor. Special scans will be used during the procedure to see where the catheter is at all times.

Once the catheter reaches the tumor, particles will be injected through the catheter to block blood flow and shrink the tumor.

There are 3 different types of embolization:

• Bland Embolization: During Bland embolization bland particles are injected into the tumor to block off it’s blood
• Transarterial Chemoembolization (TACE): the particles injected through the catheter block off the blood supply and  also contain chemotherapy medication that helps destroy the tumor.
• Transarterial Radioembolization (TARE): the particles supplied to the site of the tumor contain radioactive material that helps to destroy the tumor. If you are booked for a TARE procedure, you may need to come in for a simulation appointment a few days before the treatment so the healthcare team can take pictures of your liver and give you test doses to plan for the actual procedure.

Pain, fever and nausea can happen with the embolization procedures, but medications can be given to manage these symptoms. No matter which type of embolization procedure you have, it will usually take 1 to 2 hours. After the embolization is complete, the catheter is removed and a dressing is placed over the area the cut was made. In most cases, you will be asked to rest and lie flat for up to 6 hours.

After the Procedure:

For the first 10 days after your embolization, you should take it easy, drink lots of water, and avoid strenuous activities or lifting more than 5lbs. Each person’s recovery experience will be different. Some people may feel tired for up to 3 weeks after the embolization. If you develop fever or chills, sudden or worsening pain, trouble eating or drinking because of nausea and vomiting, bleeding or swelling at the site where the cut was made, or any other new or concerning symptoms, please contact your doctor or nurse right away.

Your healthcare team will arrange a follow-up scan (like ultrasound, MRI or CT) which will involve taking pictures of the liver and using a special contrast dye to help make the tumor area more visible. This is usually done about 1-3 months after the embolization. Based on the results of your scan, your healthcare team will decide if any more treatment for your HCC is recommended and when more scans should be done. Scans are usually done more often in the first 2 years after treatment.

You should also continue to monitor yourself for development of any new symptoms and have blood work checked as recommended so your health care team can monitor your liver.

Embolization procedures are not usually considered curative, meaning they do not cure liver cancer. Instead, they are used to shrink HCC tumors or slow down their growth. Depending on the type of embolization you have, how well it works, how many tumors you have, and your liver function, more HCC procedures may be recommended for you in the future.

Ablation is performed in the hospital, usually by a specially trained doctor called an Interventional Radiologist. It is usually performed as a day procedure, meaning you will come into the hospital, have the procedure done, and go home the same day. In some situations it could be performed in the operating room by a surgeon.

The Procedure:

Before the procedure begins, you will have an intravenous placed to give you medication. In the procedure room, you will lay on the procedure table and a nurse will set up monitors to measure your blood pressure, heart rate and oxygen levels. Depending on the type of the type of ablation, you may also have grounding pads placed under your thighs to allow electricity to exit your body. The doctor will go over the procedure and its potential risks and benefits.

The procedure will begin with you receiving sedation through your intravenous to make you more relaxed. In some cases you may be given general anesthesia. The doctor will clean your skin and inject freezing in the area over the liver where the procedure needle will be inserted.

After this, the doctor will use an ultrasound or a CT scan to guide the procedure needle through your skin, into the tumor. Once the needle is in place, the ablation can begin. There are three types of ablation that can be used to destroy the tumor.

• Radiofrequency Ablation (RFA): radio waves will be sent through the procedure needle, into the tumor. Radio waves create heat that destroys the tumor.
• Microwave Ablation (MWA): involves microwaves being sent through the procedure needle, into the tumor. Microwaves create heat that destroys the tumor.
• Percutaneous Ethanol Injection (PEI): ethanol is injected into the tumor through the procedure needle. Ethanol destroys the tumor by causing it to dry up. PEI can be used on its own, or in combination with RFA.

During the ablation procedure, you may feel mild discomfort including a feeling of heat or mild pain in the area being treated. After the ablation is complete, the procedure needle will be removed and you will be moved to a recovery area to be monitored before being discharged. The entire time you will be at the hospital is usually about 4 to 8 hours.

After the Procedure:

The tumor area that was destroyed with the ablation will turn into scar tissue.

After you go home, you should monitor yourself for symptoms. If you have severe pain or fever, please call your doctor or nurse or go to the nearest emergency department.

Your healthcare team will arrange a follow-up scan (like ultrasound, MRI or CT) which will involve taking pictures of the liver and using a special contrast dye to help make the tumor area more visible. This is usually done about 1-3 months after the ablation. Based on the results of your scan, your healthcare team will decide if any more treatment for your HCC is recommended and when more scans should be done. Scans are usually done more often in the first 2 years after treatment.

You should also continue to monitor yourself for development of any new symptoms and have blood work checked as recommended, so your health care team can monitor your liver.

Ablation procedures may be done just once or even several times on the same tumor. They can also be done in multiple spots if you have more than one tumor in your liver.

Several tests are used to diagnose HCC. The most important ones are lab tests, physical examination, and imaging tests. In some cases, liver biopsies are also done.

Lab Tests 

Your healthcare provider will order lab tests and bloodwork to check how well your liver is functioning. One of your lab tests will be an AFP test. AFP stands for alfa-fetoprotein. A high level of AFP can be a sign of HCC. If you’re considered to be at increased risk of developing lHCC, you may get an AFP test along with an ultrasound every 6 months.

Physical Exam

Your doctor might also give you a physical exam. They’ll check your skin for signs of jaundice. They might feel your abdomen for lumps or a change in the size of your liver. They’ll also check for ascites, which is a buildup of fluid in the abdomen (belly).

Imaging Tests

Imaging tests are key to diagnosing HCC. HCC can usually be diagnosed solely by imaging tests such as ultrasound, MRI, and CT scan.

Ultrasound

An ultrasound of the abdomen is often the first imaging test that’s ordered. It can identify abnormal masses in the liver such as a tumor. It’s also used to screen for HCC in people who have a higher risk of developing the disease. High-risk patients usually get an ultrasound every 6 months to screen for HCC.

CEUS (Contrast Enhanced Ultrasound)

This is a type of ultrasound that uses microbubble contrast dye to look for tumprs in the liver. There’s no problem doing CEUS with poor renal function. CEUS is only available in a few highly specialized centres.

MRI

An MRI can provide more detail about blood vessels, organs, and lymph nodes. It’s useful for showing subtle differences in cells, and it can make it easier to see the liver and any tumors when there is fat in the liver.

When you get an MRI, you’re injected with a special dye called a contrast. If you have kidney problems or an allergy to iodine, the contrast dye most commonly used for MRIs might be safer for you than the one used for CT scans.

CT Scan

A CT scan combines a series of X-ray views taken from many angles to create a 3D image. It’s associated with a higher exposure to radiation.

CT scan images can provide much more information than plain X-rays. For HCC, a CT scan can show tumors and the blood vessels that the tumors might be growing into or around. A CT scan can also look at surrounding organs and check if the cancer is spreading into lymph nodes and other areas.

When you get a CT scan, you’re injected with a special dye called a contrast. The contrast dye makes the liver more visible.

Liver Biopsy

A liver biopsy removes cells or tissues from your liver so they can be viewed under a microscope for signs of cancer.

A biopsy isn’t usually required to diagnose liver cancer. However, if the tumor doesn’t look like a typical HCC on a CT scan or MRI, a biopsy can be helpful to ensure the diagnosis is accurate prior to treatment.

TIPS is a procedure that lowers pressure in the portal vein. That’s the vein that moves blood to your liver. The medical name for it is transjugular intrahepatic portosystemic shunt. Most people just call it TIPS.

When pressure in the portal vein gets too high (called portal hypertension), it can back up and make the veins around your stomach and esophagus, or food pipe, swell. These swollen veins are called varices. If they swell too much, they break open and bleed. This is called variceal bleeding. High pressure can also cause fluid to leak out and build up in your belly (ascites) or around your lungs (pleural effusion).

Doctors might use a TIPS procedure to treat variceal bleeding, ascites, or pleural effusion, when other treatments aren’t working.

The Procedure

Before the procedure, you’ll get a general anesthetic that puts you to sleep. The doctor will insert a thin, flexible tube, called a catheter, into a blood vessel in your neck. They’ll use an imaging test, usually an x-ray with contrast dye, to guide the catheter until it gets to your liver. Then the doctor will create a channel from the hepatic vein (the vein that takes blood out of the liver), to the portal vein. This channel allows blood to bypass your liver.

The TIPS stent, which is a wire mesh tube, will be placed to keep the channel open. Then, the doctor can measure the blood flow in your veins to make sure the pressure drops. If it’s still too high, they might use a balloon on the catheter to open the stent wider. The procedure usually takes 2 to 4 hours.

After the Procedure

After the procedure, you’ll stay in the hospital, but most people can go home after a day or 2. It can take weeks or months for the TIPS to work. So if you have fluid build-up in (ascites or pleural effusion), it may take time for the fluid to go away.

After you go home, rest and drink lots of water. For at least 10 days, don’t do heavy exercise (like running), and don’t lift more than 10lbs (4.5 kg). You can still do gentle activity, like walking, each day.

It’s really important to watch for symptoms like memory trouble, feeling sleepy, and balance problems. Also watch for yellow skin and swollen legs. Call your doctor or nurse right away if you have any of these symptoms.

You’ll need to have follow-up tests to help your healthcare team check your progress. The TIPS stent can get narrower over time. If this happens, you may need another procedure to make it wider.

Risks and Side Effects

A TIPS procedure can help you feel better and lower your chances of complications from varices, ascites and pleural effusion. But just like any procedure, there are risks and side effects you should know about. You’ll do tests before the procedure to check your risk of side effects.

Because it’s the liver’s job to filter toxins out of your blood, sending some blood through the TIPS means less of it goes through the liver to get filtered. This can cause toxins to build up in your body. Toxin buildup is called hepatic encephalopathy. It can cause you to feel confused, have balance problems, and feel sleepy. About 3 out of 10 people will get hepatic encephalopathy after a TIPS. It can usually be treated with medicine.

Some people might have more liver problems because less blood goes to the liver. Or they might have heart problems because more blood flows into the heart through the TIPS. If you get major problems that can’t be managed with medicine, your doctor may block off the TIPS stent.

Other side effects are rare. This procedure could cause bleeding, infection, or damage to your kidneys or lungs

Thoracentesis is a procedure that uses a needle to drain fluid from the space around the lungs (called pleural effusion)

It can be caused by many different conditions, including cirrhosis. If you have a pleural effusion, you may have pain or feel short of breath.  Your healthcare team might suggest a thoracentesis to remove a large amount of fluid from around your lungs to make it easier for you to breathe. Or, they might want to collect a fluid sample for testing.

The Procedure

Before your procedure, the doctor or nurse practitioner will check your chest for a good spot to insert the needle. They’ll do this by tapping on your chest or by ultrasound, where sound waves are used to show a picture of the fluid. When they’ve chosen the best spot, they might put freezing medicine under your skin. This will numb the area and should make you more comfortable. You may still feel a very brief, sharp pain during the procedure.

Next, they’ll insert a needle to drain the fluid. If there’s a lot of fluid, they’ll drain it into containers connected to the needle by a small tube. When the fluid has finished draining, they’ll remove the needle and bandage the spot.

After the Procedure

Sometimes, your healthcare team will order a chest x-ray after your procedure to see if there’s any fluid left, or to check for problems. They might also check your fluid to make sure you don’t have an infection. If they find out that your fluid has an infection, you may be admitted to the hospital for treatment.

If you go home the same day as your procedure, you’ll probably be at the hospital for 2 to 3 hours. But if you need a lot of fluid drained, you’ll probably be admitted to the hospital for a day or 2.

After the procedure, keep your bandage on for 24 hours. Then, if there is no fluid leaking from the needle site, you can remove the bandage and have a shower. You can wash the needle site gently with soap and warm water. You might feel sore for a few days, but you can go back to your normal activities unless your nurse or doctor gives you other instructions.

If you have a pleural effusion, it’s very important to eat less salt. This helps slow down the fluid buildup around your lungs. Some people need a thoracentesis only once. Others need one every week or 2. Your healthcare team will work with you to decide how often is best for you.

Risks and Side Effects

Just like any medical procedure, thoracentesis has risks you should know about. In rare cases, infection, bleeding, or damage to the liver or spleen can happen. Also, there can be a small risk of a partial collapse of the lung. Sometimes, air can enter the space around the lung. This is called a pneumothorax.

If you have trouble breathing after the procedure, or have pain, fever, bleeding, or fluid is leaking from the needle site, call your doctor or nurse or go to the emergency department right away.

Paracentesis is a procedure that uses a needle to drain fluid from the abdomen (called ascites). Ascites can be caused by other conditions, but here we will go over having a paracentesis for ascites caused by cirrhosis. If you have ascites, you may have pain, feel short of breath, or have trouble eating because your belly feels full.

If you have these symptoms, your healthcare team might suggest a paracentesis to remove a large amount of the fluid from your belly. Or, they might want to collect a fluid sample for testing.

The Procedure

Before your procedure, the doctor or nurse practitioner will check your belly for a good spot to insert the needle. They’ll do this by tapping on your belly or by ultrasound, where sound waves are used to show a picture of the fluid.  When they’ve chosen the best spot, they might put freezing medicine under your skin. This will numb the area and should make you more comfortable. You may still feel a very brief, sharp pain during the procedure.

Next, they’ll insert a needle to drain the fluid. If there’s a lot of fluid, they’ll drain it into containers connected to the needle by a small tube. They might ask you to change position to help drain the fluid more easily. When your fluid has finished draining, the team will remove the needle and bandage the spot.

If you had a lot of fluid, your doctor or nurse practitioner might prescribe a protein called albumin. You take albumin through an intravenous, or IV, which is a small tube or needle put in a vein. It lowers your risk of problems from the drainage.

You’ll likely be at the hospital anywhere from 2 hours to a full day. It depends on how much fluid you have drained and how much albumin you need.  If they find out your fluid has an infection, you’ll probably be admitted to the hospital for treatment. This is not common, but it can happen.

After the Procedure

After the procedure, keep your bandage on for 24 hours. Then, you can remove it and have a shower. You can wash the needle site gently with soap and warm water.  You might feel sore for a few days, but you can go back to your normal activities unless your nurse or doctor gives you other instructions.

Some people need a paracentesis only once. Others need one every week or 2. Your healthcare team will work with you to decide how often is best for you. If you have ascites, it’s very important to eat less salt. This helps slow down the fluid buildup in your belly and give you more time until your next paracentesis.

Risks and Side Effects

Just like any medical procedure, paracentesis has risks you should know about. In rare cases, infection, bleeding, or a tear in the lining of the intestine can happen.

If you get belly pain, fever, bleeding, or fluid is leaking from the needle site, call your doctor or nurse or go to the emergency department right away.

Liver biopsy is a procedure used to collect a small piece of liver tissue, so it can be looked at under a microscope. Most people with cirrhosis don’t need a liver biopsy, but there are some situations where it is recommended.

The Procedure

Liver biopsy is usually done by inserting a needle into the liver. The doctor decides the best spot by examining your abdomen and chest. Ultrasound might also be used to chose the spot. This is called ultrasound guided liver biopsy. Freezing medicine is usually injected under the skin to make the area numb. Then the doctor inserts the biopsy needle into the liver and removes a small piece of liver tissue.

If you have significant problems with blood clotting, the biopsy can be done by inserting a small tube (called a catheter) through the jugular vein in your neck. The biopsy needle is then guided to the liver through the catheter and a small piece of liver tissue is removed. This is called transjugular liver biopsy.

Some people have no pain with liver biopsy. Others have brief pain that may spread to the right shoulder. After it’s collected, the piece of liver tissue is placed in a container and set to the lab to be looked at by a doctor called a pathologist.

After the Procedure

After this biopsy, the team will check on you often. You’ll probably stay in the recovery area for a few hours. Most people are able to go home the same day. You should make arrangements for a responsible adult to take you home.

After you go home, rest and drink lots of water. Ask the healthcare team when it is safe for you to remove the dressing from your skin and when you can shower. For at least 7 days, don’t do heavy exercise (like running) and don’t lift more than 10lbs (4.5 kg). You can still do gentle activity, like walking, each day. Don’t take baths or go swimming until the site is completely healed.

Watch for signs of bleeding or infection, like fever, new or worsening pain, and dizziness. Call your doctor or nurse right away if you have any of these symptoms.

Risks and Side Effects

The main risk of liver biopsy is bleeding. To reduce your risk of bleeding, your healthcare team will check your blood clotting before the procedure. If you are at higher risk of bleeding, they may give you medicine or blood products to lower your risk.

Other risks include damage to organs, such as the kidney, lung, gallbladder or colon and infection. The risk of death from liver biopsy is extremely low.

Upper endoscopy is a procedure that’s also called gastroscopy. It’s a way to look inside your esophagus  (food pipe), stomach, and the upper part of your small intestine. It can be done to look for and treat many conditions. For people with cirrhosis, it’s usually done for swollen veins called varices. Your healthcare team might recommend an upper endoscopy if you’re at risk for varices or if you’re bleeding.

Varices form when pressure in the portal vein (the one that takes blood to the liver) gets too high. They can be dangerous because if they get too big, they can break open and bleed.

The Procedure

Before the upper endoscopy, you’ll be asked not to eat or drink for at least 6 to 8 hours.

When you come into the procedure room, the doctor might numb the back of your throat with a spray. You’ll lie on your left side, and an endoscopy team member will put a mouthguard in place to protect your teeth. You’ll get medicine through an intravenous, or IV, which is a small tube or needle put in a vein. This will help you relax and prevent pain. You probably won’t remember the procedure.

The doctor will put a long, thin tube with a light and camera—called a scope—through your mouth. They use the scope to look in your esophagus and stomach for varices. Varices can be big or small.

If you have large ones in your esophagus or if they’re bleeding, the team might do a band ligation, called banding for short. This is when the doctor gently suctions up the enlarged vein and puts a tiny rubber band around it. In time, the band falls off and will pass through your bowels.

If you have varices in your stomach that need treatment, the doctor will inject them with a glue-like substance that causes the blood inside to harden. This is called sclerotherapy.

After the Procedure

After the upper endoscopy, the team will check on you often. You’ll probably stay in the recovery area for 1 or 2 hours. When it’s safe for you to leave, have a responsible adult drive you home. You may feel sleepy for a while. Don’t do things that need close attention—like driving or signing documents—for at least 8 hours.

As with any procedure, upper endoscopy can have side effects. These side effects are rare. They include bleeding or damage to the lining of your esophagus, stomach, or small intestine. Pay attention to how you feel in the days after your upper endoscopy. If you had banding, you might have some pain or discomfort when you swallow. Drinking fluids and eating soft foods can help. If you have bad pain or you can’t swallow, tell your healthcare team right away.

Go to the emergency department if you throw up blood, have black bowel movements, get a fever, or have trouble breathing.

Depending on what your upper endoscopy showed, you may need more procedures in the coming weeks or months. Your healthcare team will let you know.

Swelling in the legs, ankles, and feet is called peripheral edema. It happens when your body holds on to salt and water. Peripheral edema can happen to people with cirrhosis, especially after they sit or stand for a long time. In addition to cirrhosis, it can sometimes be caused by other conditions like heart failure, infection, blood clots, or kidney disease.

Treatment

Low Sodium (Salt) Diet

Too much sodium (salt) can make your swelling worse, so it’s important to lower your sodium intake.

• People with cirrhosis should eat LESS THAN 2,000 mg of sodium per day (as a reference, 1 teaspoon of salt, including sea salt, table salt or rock salts have 2300 mg of sodium). Much of the salt we eat is found in our packaged and processed foods and we might not even realize it’s there!
• There can be a lot of sodium in packaged and canned foods; See this guide to sodium to help you chose which foods to eat
• Don’t add salt to your food or cooking; herbs, spices, and marinades can help improve the flavour of food without adding sodium

For more information, check out the Nutrition in Cirrhosis Guide Book for Patients

Medications

Diuretic medicines (water pills) like lasix and spironolactone can help get rid of the fluid causing swelling. Talk with your doctor or nurse practitioner about whether these medicines would be a good option for you.

What is Pleural Effusion?

Pleural effusion (or hepatic hydrothorax) is the buildup of fluid in the space between the lungs and the chest wall (called the pleural space). When fluid builds up in the pleural space, the lungs may not be able to expand completely. This can make it hard to breathe. The lung, or part of it, may also collapse.

In cirrhosis, pleural effusion is cause by high pressure in the portal vein (called portal hypertension). In many cases, the fluid build up starts in the abdomen (ascites) but eventually passes through holes in the diaphragm, into the chest (pleural effusion).

Symptoms of pleural effusion can include:

• chest pain
• cough
• trouble breathing or shortness of breath

Pleural effusion is usually diagnosed with a physical exam and tests like a chest X-ray or CT scan. To help find out what caused the fluid to build up, your doctor may also order bloodwork or lab tests on a sample of the fluid from around your lungs.

Treatment

A very small pleural effusion may not cause any symptoms or need to be treated. In other cases where the pleural effusion is causing symptoms or there is concern about infection, treatment may be needed.

Low Sodium (Salt) Diet

Too much sodium can make your body hold on to extra fluid. This fluid can pool in your belly, chest and legs. Eating foods with less sodium can help control fluid build up.

• Aim to eat less than 2000 mg of sodium a day.
• One teaspoon of salt has about 2300 mg of sodium.
• All types of salt contain the same amount of sodium, including table salt, sea salt, and Himalayan salt.

Tips to reduce sodium:

• At first, foods may taste bland. Over time, your taste buds get used to less salt.
• Don’t add salt to your food while cooking or at the table.
• Choose fresh, unprocessed, and homemade foods.
• Eat less processed, packaged, or restaurant foods.
• Limit condiments and sauces (ketchup, mustard, soy sauce, gravies, salad dressings).
• Limit pickled foods, olives, chutneys, and dips.
• To boost flavours, try adding spices, seasoning mixes with no salt added, lemon, lime, vinegar, fresh or dry herbs, garlic, or onions

Read food labels

Diuretic Medicines

Diuretic medicines such as furosemide and spironolactone can also help to get rid of the fluid that has built up around your lungs and other parts of the body. They help to both prevent and treat problems with pleural effusion.

If you are taking diuretics, it is important to weigh yourself daily to monitor the effect of diuretics. One litre of pleural fluid weighs about 2.2 pounds (1 kg). Gradual weight loss is a sign of decreasing pleural effusion – this is expected and desired when diuretics are first started. Losing weight too quickly can be dangerous.

You should also have your blood work checked as recommended by your healthcare team because diuretics can effect your kidneys and electrolyte levels. Your dose of diuretics can be adjusted by your healthcare team if you are losing weight too quickly, having side effects, or they don’t seem to be working.

Let your healthcare team know if you are experiencing:

• dizziness
• a decrease in urination
• confusion or sleepiness
• have ongoing or worsening trouble with breathing
• are losing weight too quickly: 2 pounds (0.9 kg) or more in a day, for 2 days in a row, OR more than 7 pounds (3.2 kg) in a week

Thoracentesis

Thoracentesis is a procedure used to drain pleural fluid.

Sometimes thoracentesis is used to take a sample of the fluid for determining why it’s building up. Thoracentesis might also be used if you have cirrhosis and the following circumstances:

• You have a large amount of pleural fluid. It’s causing extreme discomfort and difficulty breathing. A thoracentesis may relieve these symptoms before you begin treatment with one or more diuretics.
• You haven’t responded to a low-salt diet and diuretic medicines, or your body is unable to tolerate diuretic medications. In this situation, you may require thoracentesis repeatedly.
• Your doctor suspects the fluid is infected.

Other Treatments

Your healthcare team may recommend other treatment options. Options available to you will depend on lots of different factors like your age, other medical conditions and how sick your liver is. Some other treatment options might include:

• Transjugular intrahepatic portosystemic shunt (TIPS). This procedure that involves inserting a shunt to decrease portal hypertension by redirecting blood flow around the liver.
• Liver transplant. This is a major surgery where your liver is removed and replaced with a donor liver.
• Indwelling pleural catheter. This is a special type of catheter that’s left in place for ongoing fluid drainage.