Supplementary Material for: Lumbar inferior vena cava cannulation for hemodialysis-A lifesaving option in pediatric patients with exhausted vascular access: A case series

Introduction
Chronic kidney disease (CKD) in children poses unique challenges, especially in resource-poor developing countries, with limited facilities for renal replacement therapy (RRT). We present three cases of children with end-stage renal disease (ESRD) from Sri Lanka in whom traditional access has been exhausted secondary to sepsis and thrombosis.
Case presentations
Three patients were not candidates for peritoneal dialysis, and several attempts for tunneled and non-tunneled catheters limited the ability to continue RRT until the donor work-up for transplantation was completed. Therefore, surgical placement of a vascular catheter (vascath) to enter the inferior vena cava (IVC) directly was performed under general anaesthesia. Patient 1, a nine-year-old boy, successfully maintained dialysis through the IVC catheter until transplantation. Patient 2, a fourteen-year-old boy with extensive thrombosis, underwent successful cannulation with good outcomes at four months’ follow-up. Patient 3, a twelve-year-old girl post-nephrectomy, initially dialyzed successfully but later died due to cardiac failure unrelated to the access site. This procedure provided effective hemodialysis access, mitigating severe volume overload and hyperkalaemia. They also tolerated subsequent dialysis sessions well.
Conclusion
This case series highlights the critical role of unconventional dialysis access methods in resource-constrained settings, where advanced interventional radiology options may be unavailable. While IVC cannulation for hemodialysis is more commonly described in adults, these are the first reported cases of vascath insertion into the IVC in pediatric patients. Additionally, these findings underscore the importance of innovative strategies to manage pediatric CKD in low-resource settings, pending definitive renal transplantation.