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TRICO 2016

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Proceedings of TRICO 2016 from desk of Tejas Patel

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TRICO 2016, the Twelfth International Transradial Intervention Course was held on 15th and 16th of October, 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 2016 since the beginning of this year, and our old friends including Samir Pancholy, John Coppola, Mitchell Krukoff, Tejan Patel, Tak Kwan, Rajiv Gulati, Mauricio Cohan, Kintur Sanghavi and Fazilla Malik, agreed to be on international guest faculty. Jim Nolan, Avatandil Babunashvilli, Amit Srivatsava, Mir Jamaluddin, Amiruzzaman Khan, Sam Husnayen and Chandra Mani Adhikari 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 26 very complex cases of coronary and peripheral interventions and all of them got admitted on 14th October, 2016, at Apex. The response of participants for registration was overwhelming and before we realized, 458 participants were registered and we had to stop registering new participants almost three weeks before TRICO 2016. We had to refuse 136 registrations. Once again, there was a very heavy participation from Bangladesh (88 delegates). We had participation from twelve countries and 121 participants were from outside India. Last moment dropout rate was only 8%. Most participants and international guests arrived on 14th October, 2016. We were all set for one more power-packed course. 

On 15th October, 2016 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. I asked Sanjay to demonstrate the radial puncture technique. He did it very elegantly. 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 Xience Alpine stents for bifurcation and Synergy stent for the LCX lesion. We had very good discussion during the live demo. End result was optimal. On-site moderators Mitchell Krukoff and Rajiv Gulati also participated actively in the discussion with us and the panelists. The next case was RCA long total occlusion and a critical lesion in extremely tortuous and calcified LAD. We finished RCA stenting using Ultimaster and worked on LAD lesion. The lesion could be cracked at 24 bars using NC Euophora balloon. We had a lot of struggle deploying ONYX stent which is one of the most trackable stents. However, end result was optimal. There was a lot of discussion regarding different strategies during such situation. The third case was a type A proximal LAD lesion. We purposefully selected this case because we wanted to deploy Absorb and generate discussion on the selection criteria and deployment strategies of Absorb. There was a good interaction between us, panelists and on-site moderators. We used OCT to show the end result. It was the end of the first live demo session. There were two extremely important talks from Jim Nolan and Mauricio Cohen. They touched very important aspects of TRA. The crowd enjoyed listening to them. 

The second live demo started with the fourth case which was done by Mitchell Krukoff alongwith Kiran Prajapati. There were multiple lesions in RCA and Endoluminal reconstruction was done very nicely using three long stents including two Xience Expedition and one Ultimaster. End result was optimal. Then, John Coppola alongwith Sanjay did a complex LAD using Onyx and they fixed a critical right renal stenosis in the same patient using Herculink. It was a nice demonstration of concurrent coronary and renal stenting. Following this case, Tak Kwan alongwith Sunil Gurmukhani demonstrated stenting of a complex lesion in RCA having anamolus origin from NCC. It was an elegant demonstration by Tak using Promus Premier Stent. The on-site moderators John Coppola and Kintur Sanghvi played a very interactive role for this session. That was the end of second live demo and we had a lunch break for 45 minutes.

After lunch break, we started with a very high risk case. She was an octogenarian diabetic patient having suffered recent AWMI and having LVEF of 15%. Her coronary angiogram done before a week was showing heavily calcified 95% LMCA bifurcation stenosis and lesions in mid-LAD and mid-LCX. RCA was diffusely diseased. She was given option of CABG which was turned down by her and family. After explaining the pros and cons, we accepted her for LMCA bifurcation stenting. We deployed IABP through right groin and punctured her right radial artery for PCI. We demonstrated combo technique to track a 7F EBU guide catheter through her small radial artery. Sanjay was assisting me and we had tough time opening the calcified lesion. We were about to use rotational atherectomy. However, we took a chance inflating NC Euphora balloon and lesion opened up at 28 bars. We demonstrated modified T-stenting using two Xience Alpine stents with a clean end result. Everybody enjoyed this case. Next case was done by Samir Pancholy with Rajni Radadia. It was again a diffuse RCA disease. Samir did a great job of Endoluminal reconstruction using multiple Synergy stents and demonstrated the use of IVUS to optimise the end result. The next case was a high risk basilar artery stenting through left radial approach. Sanjay assisted me and we did it successfully using Onyx stent. We discussed strategy of stent implantation in intracranial arteries. The fourth case was a multi vessel stenting done by Sanjay alongwith Rajni. Sanjay did it very confidently and demonstrated the use of OCT to assess the end result. He used Xience Alpine and Synergy stents. Jim Nolan and Mauricio Cohan did a great job of on-site moderation. This was the end of the third live demonstration session. 

We then started with panel discussion. I anchored it and the international guest faculty participated as panelists. We have done hard work to prepare this session which was on different complications during TRA and different ways to deal with them. It lasted for almost two hours and there was a great discussion amongst the panelists and very interactive participation from the delegates. It was extremely well received. We adjourned the first day proceedings and enjoyed gala dinner from 8 p.m. to 11 p.m.

Dr. Saito arrived late on 15th evening and came to Apex at 9.30 a.m. in the morning of 16th. The first case on the 16th morning was done by Tejan Patel alongwith Chirayu Vyas. Tejan did PCI of multiple RCA lesions successfully deploying multiple stents. The second case was a very tough case. It was a calcified CTO of LAD. The great Dr. Saito was assisted by Rajni. He showed his style of dealing with this case. He used heavy CTO wires and micro catheter. He could track the wire through long CTO. He tried with several balloons. However, he changed over to rota-wire and did rotational atherectomy of long CTO and ballooned it and deployed multiple Ultimaster stents with excellent end result. Everybody enjoyed the case. On-site moderators Fazilla Malik and Amit Srivatsava also very actively participated. The third case was an anomalous RCA arising from left coronary cusp having CTO in the mid-segment. It was done by me alongwith Sanjay. There was a lot of discussion on different guide catheter curves to be tried to deal with this situation. We could successfully finish the case using Onyx stent. Following this case, Dr. Saito did another CTO case. He fixed LAD CTO so nicely. He is a great finisher. He used Xience Alpine stent and special CTO hardware. Then I alongwith Sanjay started with a nice LMCA bifurcation stenosis. We demonstrated T-stenting and ended with final kissing balloon. We used Xience Alpine stents. This live demo session continued for four hours and thirty minutes. We dispersed for the lunch break at 1.30 p.m. and again reassembled in the auditorium at 2.15 p.m. The delegates enjoyed great talks from Amit Srivatsava, Rajiv Gulati, Avatandil Babunashvilli, Kintur Sanghavi and Mitchell Krukoff. Lastly, in angio discussion session, Mir Jamalluddin, Chandra Mani Adhikari and several others showed some great work. 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 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 2017. Kindly note the dates for TRICO 2017. It is to be held on 7th and 8th October, 2017.
Tejas Patel,
Course Director,
TRICO 2016.