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TRICO 2018

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Proceedings of TRICO 2018 from desk of Tejas Patel

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TRICO 2018, the XIII International Transradial Intervention Course was held on 17th and 18th of February, this year. Unfortunately, TRICO 2017 which was planned on 7th and 8th of October, 2017 had to be cancelled because of unavoidable circumstances at that point of time. There was an increasing demand from India and neighboring countries and we were able to finalize the new dates only in the end of October, 2017. There was tremendous pressure on us to chock out the program and finalize on the list of the international guest faculty. Dr. Shigeru Saito, who has been our mentor for our transradial program had pre-occupation in Japan during these dates and he showed his inability to attend TRICO 2018. This news added to our pressure because Dr. Saito has always been a master operator and demonstrator throughout all the TRICOs. Ferdinand Kiemeneij from Netherlands (the father of TRI) agreed to join us. Our old friends including Samir Pancholy, John Coppola, Tak Kwan, Malcolm Bell, Rajiv Gulati, Mauricio Cohan, Tejan Patel, Kintur Sanghvi and Fazila Malik, agreed to be on international guest faculty. Manish Parikh from New York also agreed to be with us for demonstration of Robotic-assisted PCI. Takashi Akasaka who is one of the world authorities on OCT and FFR also consented to join TRICO 2018. Mohammad Zulfikar Ali, Ashok Kumar Dutta, Sabina Hashem, Mir Jamaluddin, Mohammad Shafiqur Rahaman Patwary and Md. Towhiduzzaman from Bangladesh also consented to be on international guest faculty. Unfortunately, at the last moment because of unavoidable circumstances, Ferdinand Kiemeneij and Manish Parikh could not make it. It was very unfortunate for us to miss them for TRICO 2018.
This time, the venue was AIIM Auditorium at Adani Shantigram Township, and the live transmission was from Apex Heart Institute, Ahmedabad. We accumulated 23 very complex cases of coronary and peripheral interventions and all of them got admitted on the 16th February, 2018, at Apex. The response of participants for registration was overwhelming and before we realized, 453 participants were registered and we had to stop registering new participants almost six weeks before TRICO 2018. We had to refuse about 178 registrations because of non-availability of the seats in auditorium. Once again, there was a very heavy participation from Bangladesh (63 delegates). We had participation from several countries and 76 participants were from outside India. Sudan, Brazil and Argentina were the new inclusions. Last moment dropout rate was 15%. Most participants and international guests arrived on 16th February, 2018. We were all set for one more power-packed course. We had several new agenda during this course including demonstration of Robotic-assisted PCI, distal transradial approach, slender approach, IVUS, OCT and FFR. 
On 17th February, 2018 at 8.45 a.m. sharp, Sanjay and I started live demo of the first case. The auditorium was jam-packed. It was a complex LAD-D1 bifurcation stenosis. I asked Sanjay to demonstrate the distal radial puncture technique. He did it very elegantly. We negotiated a slender 7F introducer sheath (Terumo, Japan). In this case, we showed utility of "combo" technique to track a 7F EBU guide catheter through small radial artery.  It was a complex bifurcation LAD-D1 stenosis. We showed mini-crush technique and kissing balloon. We used Synergy stents for bifurcation. We had very good discussion during the live demo. End result was optimal which was confirmed by OCT imaging. On-site moderators Takashi Akasaka and Rajiv Gulati also participated actively in the discussion with us and the panelists. The next case was a type-C RCA lesion for Robotic-assisted PCI. Sanjay and Yash demonstrated the preparation of the Robotic Drive and Cassette very elegantly. I demonstrated the guide catheter cannulation, wiring, pre-dilatation with balloon and deployment of a 48 mm long Xience Expedition stent step-by-step, sitting in the interventional cockpit of Corindus Vascular Robotics (CorePath GRX). We had long and fruitful discussions with the onsite moderators and penalists about this new technology. Everybody enjoyed the case. The third case was a critical LMCA bifurcation and mid-LAD stenosis. Rajni assisted me for this case. Again we demonstrated the left distal radial puncture and use of a 7F slender introducer sheath. After pre-dilatation and stenting the LAD lesion using a Xience Expedition stent, we deployed a Xience Expedition stent from LMCA to LAD, keeping a coronary wire in LCX. We wired LCX again through the struts and did kissing balloon in LMCA bifurcation and after removal of wires the final result was satisfactory. Hence, we avoided stenting the LCX ostium. Final result was confirmed by OCT imaging and we had an opportunity to learn a lot of new things from the master Prof. Akasaka. There were some extremely useful comments. 
The second live demo started with the fourth case: a Robotic-assisted PCI of an extremely tortuous type-C LAD lesion. Once again, Sanjay and Yash demonstrated the preparation and I took my place in the interventional cockpit. After cannulation of LCA, the coronary wiring was challenging and we showed how it works using a Robotic arm. After pre-dilatation, I deployed two over-lapping Onyx stents to get an optimal end result. Everybody enjoyed the case and the discussions. The fifth live demonstration case was an LCX OM bifurcation and LAD PCI. Mauricio Cohen was assisted by Sanjay. After stenting LAD with Promus Premier stent, Mauricio very elegantly demonstrated provisional T-stenting for LCX-OM bifurcation stenosis with optimal end result which was confirmed using IVUS imaging. The bilateral discussion was enjoyed very much by the delegates. The sixth case was a type-C tortuous LAD lesion and an LCX lesion which was done by Samir Pancholy with Rajni. As usual, Samir did a nice job using Orsiro stents. Final result was confirmed by IVUS imaging. There was a lunch break for one hour. 
We started our post-lunch session with two extremely important talks delivered by Rajiv Gulati and Takashi Akasaka which were very well received by the crowd. Following the talks, a live case of PCI of RCA ISR was demonstrated by Tejan Patel with Rajni. He did a nice job which was confirmed by OCT imaging. The eighth case was a difficult case of endovascular reconstruction of RCA. Kintur Sanghvi assisted me. As usual, Sanjay demonstrated left distal radial puncture and introduction of slender sheath. We crossed a long diffuse total occlusion using a pilot 150 coronary wire with the help of Fine Cross Micro Catheter. After segmental dilatation, we deployed two over-lapping Promus Premier stents. We post-dilated the whole segment and did OCT imaging to confirm the end result. Malcolm Bell, the on-site moderator for the session generated an excellent discussion throughout the demonstration. The ninth live demonstration was again a Robotic-assisted PCI of a critical LAD stenosis. Again we discussed every single step of the procedure. Malcolm Bell and I had lot of interactions regarding this new technology and its future. The panellist also participated actively throughout. The lesion was stented using Ultimaster stent and end result was satisfactory. The last case of the first day was a very complex ostial LCX and LAD PCI. We considered and treated this case as LMCA bifurcation. We did FFR of the LAD lesion, which was 0.78 and Malcolm Bell generated a long discussion with the penal on FFR, IFR and their utility. I found it very educative for me. We did T-stenting of LMCA bifurcation and kissing balloon to achieve optimal end result.  We adjourned the first day proceedings and enjoyed gala dinner from 8 p.m. to 11 p.m. at Belvedere Golf and Country Club.
The first case on the second day was concurrent PCI of LAD and right renal artery stenosis. John Coppola was assisted by Sanjay. He is a very experienced radial operator and he did a good job to address both the lesions. Crossing the tortuous subclavian and aortic arch to enter the descending aorta was challenging but he demonstrated it nicely. The second case was PCI of LAD and LCX lesions to be done through arteria lusoria using right TRA. I was assisted by Rajni. I demonstrated a step-by-step approach for working through arteria lusoria and cannulating the LCA. I am sure everybody got interested and liked it. The end result was optimal. The third case was a Robotic-assisted PCI of a type-C RCA stenosis. Again we showed every single step during the procedure. The on-site moderators Fazila Malik and Takashi Akasaka actively participated in the discussion. The fourth case was a complex LMCA bifurcation PCI. I was assisted by Sanjay. We demonstrated the step-by-step of T-stenting with optimal end result which was confirmed by the OCT imaging. The last case before Lunch was a multi-vessel PCI using right distal transradial approach, which was done by Tak Kwan with Rajni. As usual, Tak did a great job and very confident throughout. He very elegantly demonstrated the use of the same JL4 guide catheter to cannulate RCA for PCI. The end result was clean and OCT imaging confirmed it. We ended our live demo session and dispersed for a short Lunch break. 
After lunch, there were excellent talks delivered by Malcolm Bell and Samir Pancholy. Kintur Sanghvi and Sunil Gurmukhani also delivered very informative talks. Following that there was discussion on several complex case presentations done by Sunil Gurmukhani and Saurabh Potdar. At last, we had a penal discussion for one hour. There was a lot of interaction and discussion throughout. At 5:30 p.m. I concluded with vote of thanks and we officially ended TRICO 2018. 
I express my sincere thanks and gratitude to 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 2019. Kindly note the dates for TRICO 2019. It is to be held on 1st and 2nd of February, 2019.
Tejas Patel,
Course Director,
TRICO 2018.