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TRICO 2015

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Proceedings of TRICO 2015 from desk of Tejas Patel

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TRICO 2015, the Eleventh International Transradial Intervention Course was held on 31st October and 1st of November, this year. Again, the venue was Nirma University Auditorium and the live transmission was from Apex Heart Institute, Ahmedabad. We started the preparation for TRICO 2015 since the beginning of this year, and our old friends including Samir Pancholy, John Coppola, Mitchell Krukoff, Tejan Patel, Ian Gilchrist, Tak Kwan, Yves Louvard, Sasko Kedev, Rajiv Gulati, Malcolm Bell, Kintur Sanghavi, Fazilla Malik, Mitrakumar and Naomali Amarsena agreed to be on international guest faculty. Ajay Kirtane, M. G. Azam, Mir Jamaluddin and Futoshi Yamanaka also consented for the same. It was an honor for us once again to have Dr. Shigeru Saito as Course Director alongwith me and Sanjay. We accumulated 25 very complex cases of coronary and peripheral interventions and all of them got admitted on 30th October, 2015, at Apex.  The response of participants for registration was overwhelming and before we realized, 474 participants were registered and we had to stop registering new participants almost one month before TRICO 2015. We had to refuse almost 151 registrations. We saw heavy participation from Bangladesh (48 delegates). We also had participation from Sri Lanka and neighboring countries. Last moment dropout rate was 12%. Most participants and international guests arrived on 30th October, 2015. We were all set for one more power-packed course. 
On 31st October, 2015 at 8.45 a.m. sharp, we started live demo of the first case. It was a complex LAD-D1 bifurcation stenosis and a complex LCX stenosis.  Sanjay assisted me. In this case, we showed utility of "combo" technique to track a 7F EBU guide catheter through small radial artery.  We also showed a good demonstration of radial puncture technique. It was a complex bifurcation LD-D1 stenosis. We showed mini-crush technique and kissing balloon. We used Promus Premier stents for bifurcation and Ultimaster stent for tortuous LCX lesion. We had very good discussion during the live demo. End result was optimal. The next case was RCA CTO. We started with Finecross Microcatheter and Pilot 50 guidewire. We changed over to Pilot 150 and Progress 40 CTO guidewires. We could not negotiate the lesion. There was a lot of discussion on different strategies to address CTOs. On site moderators (Mitchell Krucoff and Malcolm Bell) also participated very actively in the discussion.  We gracefully accepted the failure because we did not want to make it an ego issue and harm our patient. It was appreciated by the crowd. The third case was an LAD-D1 bifurcation and D1 was a medium to small artery with reasonably clean ostium. LAD was having a critical non-calcific lesion on a straight segment. We wired LAD and D1 and dilated LAD lesion with 3 x 12 mm Mavrick balloon at 12 bars. We deployed Absorb bioresorbable scaffold at 8 bars. In-scaffold dilatation was done with NC-track 3 x 15 mm balloon at 18 bars. End result was optimal. We wanted to show the OCT, however, there was some technical snag with OCT machine and we could not demonstrate that. There was discussion about deployment strategy as well as selection of cases for BVS. There was great participation from panel as well as audience.  
The fourth case was again a complex LAD-D1 bifurcation stenosis as well as a long RCA stenosis. It was performed by Dr.Yves Louvard and Dr. Kiran. The end result was excellent using two Xience Expedition stents and mini crush technique. They used IVUS several times during the case. Everybody enjoyed the case. After this case, Ajay Kirtane delivered an excellent talk on TRA: Current Status. Rajiv Gulati gave a talk on TRA for peripheral interventions: Expanding the Horizon. Both talks were extremely well received by the audience. 
The fifth live case was performed by John Coppola alongwith Sanjay. It was a multi-vessel intervention through left TRA. The radial artery had a loop and an elegant demonstration of balloon assisted tracking technique was done. They deployed Resolute Onyx and Ultimaster Stents with clean end result. A good discussion on left radial approach and BAT technique was done. The sixth case was also a multi-vessel intervention to be done through transulnar approach by Sasko Kedev and Pankaj Joshi. A good discussion took place about pros and cons of transulnar approach as well as the puncture technique and hemostasis. It was completed using Xience Expedition Stents with satisfactory end result. That was the end of pre-lunch session.  
In post lunch session, the seventh case was an instent LAD lesion and an LCX lesion. It was performed by Samir Pancholy with Rajni. Samir addressed LAD instent lesion using Synergy stent. He confirmed the result using IVUS. A good discussion took place on the IVUS findings. LCX lesion was addressed using Ultimaster Stent. End result was also confirmed using IVUS. The case ended well. The eighth case was LCX OM bifurcation stenosis. It was performed by Mitchell Krukoff with Pankaj Joshi. Mitch initially planned to deploy BVS, however, after dilatation he changed his strategy and deployed Resolute Onyx with good end result. He also did IVUS examination at the end. The ninth case was an LAD-D1 bifurcation followed by a complex CTO and a long LCX lesion. It was done by me alongwith Sanjay. Wiring of LAD-D1 bifurcation and CTO was done at some other center before five days without success. We started with Run-through floppy guidewire alongwith Finecross catheter. Wire had tendency to enter different false channels made previously in other center. We tried using different wires and different tricks. A lot of discussion took place between the panel and us. After sincere effort of almost one hour, we abandoned the procedure. It was quite disappointing. However, the crowd appreciated the effort. Tenth case was a complex tortuous RCA having two tight lesions on bends. Tejan Patel alongwith Rajni performed it. It was a nice demonstration of Resolute Onyx Stent deployment. There was a distal dissection which had to be addressed using Resolute Onyx going through the stent and tortuosity. End result was satisfactory. By this time, it was 6 p.m. in the evening and we had to end the day postponing the panel discussion for the second day afternoon.  At 8.30 p.m., the faculty and participants had gala dinner in Karnavati Club Lawn. 
Second day we started at 9.00 a.m. sharp. The first case was done by great Dr. Saito and Dr. Kiran with Rajni. It was an LAD-D1 bifurcation and a long RCA lesion. It was done very quickly using Xience Expedition Stents. The result was confirmed by IVUS examination. The second case was done by me with Sanjay. It was an extremely difficult LCX OM bifurcation having 120o angle. We used Run-through extra floppy wire. Sanjay gave a very special shape to the tip. A lot of strategies were discussed about entering the LCX through the complex angle. We could demonstrate our technique very successfully and was appreciated very much by the panel and audience. We stented the LCX lesion using Resolute Onyx across the OM branch. Then with BMW wire we entered OM branch through the struts and struts were dilated using 2 x 10 mm Tazuna balloon. Following that T-stenting was done using another Onyx stent and last kissing balloon was done with excellent end result. The third case was done by Dr. Saito alongwith Dr. Kiran and Rajni.  It was a long CTO of LAD with blunt stump. Both radials were punctured. Using Tiger Catheter RCA injections were done to see the collaterals of LAD. Dr. Saito used special Japanese CTO wires to cross LAD CTO successfully. The crowd was stunned. He did aggressive dilatation to prepare the bed and deployed 3.5 x 28 mm Absorb bioresorbable scaffold. He discussed his strategy of Absorb deployment. He confirmed the deployment using IVUS. It was an excellent case. The fourth case was a long calcified LAD lesion and a long RCA lesion. It was done by me with Sanjay. We showed rotational atherectomy through transradial approach successfully. A good discussion of rotational atherectomy was done. We deployed Synergy stent with clean end result. RCA was also stented using the same stent. The fifth case was the transpedal intervention of an instent SFA lesion. It was done by Dr. Tak Kwan, and Sanjay. They took help of Dr. Darshan Majmudar, who is one of the finest sonologist around. Dorsalis Pedis artery was punctured under ultrasonic guidance and a 4F sheath was deployed. The instent CTO of SFA was crossed and long balloon dilatations were given to achieve an optimal end result. Tak is one of the world experts for transpedal approach. The case was terrific and the audience enjoyed it. The sixth case was an ectatic RCA and a long complex lesion which was done by Dr. Yves Louvard and Dr. Chirayu.  It was done successfully using a long Onyx Stent. During post-dilatation, there was a small perforation, which was identified and addressed immediately using a covered stent. Though it was a lunch break, half of the hall was full to watch how the problem was addressed. Again it was an excellent demonstration. This was for the second time in 11 consecutive TRICOs we did not keep any lecture in one session and from 9 a.m. to 1.30 p.m. it was a continuous live demonstration session.  
In post lunch session, we had some important didactics from Malcolm Bell, (on Primary PCI-Pluses and Minuses), Adhir Shroff (on TRA and Outpatient PCI), Kintur Sanghvi (on TRA for Structural Heart Disease), Ian Gilchrist (on Future of TRA), Mitchell Krucoff (on What I have learned from TRICO and how it helped?) and P Manokar (on Trans Radial Venous Access). Following that, three complex cases were presented by Sharad Jain, Jayesh Prajapati and Amal Kanti Sen. It was 4 p.m. then. I asked the participants whether they want panel discussion or we conclude the course. There was a strong opinion for going ahead with panel discussion. We started it with our international guest faculty. I must tell you that Sanjay and I alongwith Yash Soni worked very hard to prepare this case-based panel discussion. There was a great participation from both international guest faculty and delegates. We discussed a lot of traps and tricks related to transradial technique. At 5.00 p.m. I suggested to conclude. However, there was again a demand from the delegates to continue but our international guests had to keep-up with the timings of their flights, so we continued for another 15 minutes and I had to conclude the course at 5.15 p.m. I concluded with vote of thanks and announcement of TRICO 2016 (dates: 15th and 16th October, 2016). 
I express my sincere thanks and gratitude to Dr. Saito, all the international guest faculty, as well as national guest faculty for helping me to create one more success story. 
Looking forward to having you all for TRICO 2016. 
Tejas Patel
Course Director
TRICO 2015