Proceedings of TRICO 2014 from desk of Tejas Patel


TRICO 2014, the Tenth International Transradial Intervention Course was held on 11th and 12th 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 2014 since the beginning of this year, and our old friends including Samir Pancholy, John Coppola, Mitchell Krucoff, Tejan Patel, Ian Gilchrist, Michael Cowley, Tak Kwan, Sunil Rao, Yves Louvard, Sasko Kedav, Olivier Bertrand, Rajiv Gulati, Malcolm Bell, Kintur Sanghavi and Fazilla Malik agreed to be on international guest faculty. Unfortunately, Olivier Bertrand, Yves Louvard, Rajiv Gulati and Malcolm Bell could not make it this time. 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 10th October, 2014, at Apex. We faced a challenge this time because three national conferences for interventional cardiologists collided on the same dates. However, the response of participants for registration was overwhelming and before we realized, 426 participants were registered and we had to stop registering new participants almost one week before TRICO 2014. Unfortunately, we did not have any slots for nurses and technicians this time so reluctantly, we had to refuse 126 registrations. We saw heavy participation from Bangladesh (25 delegates). We also had participation from Sri Lanka and Middle East countries. Last moment dropout rate was 16%. Most participants and international guests arrived on 10th October, 2014. We were all set for the power packed course.

On 11th October, 2014 at 8.45 a.m. sharp, we started live demo of the first case. It was a complex LMCA bifurcation stenosis. Sanjay assisted me. In this case, we showed utility of modified mother-and-child 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 LMCA stenosis and there were two big branches (Ramus) arising from the bifurcation. We used three wires and showed provisional T-stenting and kissing balloon. We had very good discussion during the live demo. End result was optimal using Xience Expedition stent. The next case was a heavily calcified almost total occlusion of RCA. We wanted to show rotational atherectomy, but, with balloon we could dilate the lesion well and we demonstrated use of overlapping absorb (bioresorbable vascular scaffold) implant. There was discussion about deployment strategy as well as selection of cases for BVS. There was great participation from panel as well as audience. We also demonstrated the use of OCT to evaluate the final result.

The third case was a complex LAD – D1 bifurcation stenosis. It was performed by great Dr. Saito and was assisted by Rajni. Dr. Saito with his level of expertise and experience, also struggled quite a bit. However, the end result was excellent using three Xience Expedition stents and mini crush technique. He used IVUS several times during the case. Everybody enjoyed the case. After this case, Sunil Rao delivered an excellent talk on over-view of TRA. Samir Pancholy gave a talk on patent hemostasis and Mitchell Krukoff delivered a talk on orbital atherectomy through TRA. All the three talks were extremely well received by the audience.

The fourth live case was performed by Samir Pancholy alongwith Kiran. There were two lesions in calcified and extremely tortuous LAD. After dilatation, Promus Element Plus stent was not moving beyond the first lesion and he had to deploy it in the first lesion. He took Promus Premier stent to track it through the first stent but it was not moving beyond it. He then used Fine Cross micro catheter and deployed High Torque Wiggle guide wire to successfully track the stent distally and deployed it in the second lesion. It was an excellent demonstration of Wiggle wire. The fifth case was done by John Coppola with Sanjay. It was a case of critical SVC obstruction. It was done through the cubital vein using a 90 cm long Destination sheath. A 14 mm diameter self expanding stent from Boston Scientific Company was deployed successfully. It was the first such case done by us. The end result was perfect. The last case of first session was done by Sanjay with Pankaj. It was a case of critical left renal artery stenosis which was done through the left radial approach. Sanjay very elegantly demonstrated the case with clean end result.

In the post lunch session, the seventh case was done by Dr. Saito with Rajni. It was a case of extremely complex LCX-OM bifurcation. Dr. Saito struggled but the end result was satisfactory. There was a lot of discussion between Dr. Saito, moderators and audience. Everybody enjoyed. The eighth case was an eleven year old CTO in LAD and was done by me and Sanjay. We struggled and struggled to cross using every single CTO wire we had. We tried all the tricks using the wires, balloons and Fine Cross micro catheter but we could not succeed. There was a lot of discussion and suggestions from the moderators. Although, we failed, the case had great educational value. The ninth case was done by Tejan with Kiran. It was an in stent stenosis of LAD, which was very elegantly addressed by him. Following that, there were three talks. First one by Ian Gilchrist on understanding the anatomy for TRA. Ian in a very professorial style delivered it nicely. Second one was by Michael Cowley on history of coronary interventions. It was actually an extra-curricular talk, but, the crowd enjoyed it very much. The last talk of the day was delivered by Sasko Kedav on transradial carotid interventions, which was excellent. We could finish the first day proceedings absolutely on time. At 8.00 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 having two LAD stenoses. It was performed by Michael Cowley with Chirayu. He did it very nicely using Promus Premier. There was an excellent discussion on clopidogrel v/s. presugrel v/s. ticagrelor. There was also a long discussion on Angiomax. The audience asked a lot of questions which were addressed by the panel and Mike. The second case was done by Mitchaell Krukoff with Pankaj. It was an LAD CTO and a type-C lesion in the LCX. Mitch nicely demonstrated the case. The end result was perfect. The third case was done by me alongwith Sanjay. It was a tight LAD lesion, CTO of major diagonal arising from LAD and a CTO of mid-RCA. We dilated the diagonal but did not stent it as the caliber was very small. We deployed Absorb in LAD. We again discussed the strategies for Absorb deployment and selection criterias. We used OCT to demonstrate the end result. Then we addressed a complex RCA CTO in the same patient using two Resolute Integrity stents with clean end result. The fourth case was again a CTO. It was an LAD CTO, with LCX-OM bifurcation, which was addressed by great Dr. Saito very elegantly. The fifth case was probably the first transpedal intervention of the country. It was done by Dr. Tak Kwan, Sanjay and us. We 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 CTO of popliteal artery and a long lesion of superficial femoral artery were 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 again a 15 year old proximal LAD in stent CTO which was beautifully addressed by Dr. Saito. He received a lot of applause from the audience. This is for the first time in 10 consecutive TRICOs we did not keep any lecture in one session and from 9 a.m. to 1 p.m. it was a continuous live demonstration session. Dr. Saito was half way through at 1 p.m. in his case and we announced lunch break but audience did not want to move and the session was stretched upto 1.30 p.m. It was a continuous 4 hours 30 minutes of live session.

In post lunch session, we had some important didactics from Samir Pancholy (on radial puncture technique), Tak Kwan (on transpedal approach), Sasko Kedav (on transulnar approach), Kintur Sanghavi (on transradial renal interventions) and myself (on balloon assisted tracking). Dr. Suresh Kaul delivered a talk on transradial stemi interventions in remote area. I was touched by his talk. At 5 p.m., we closed the course with vote of thanks and announcement of TRICO 2015 (dates : 31st October and 1st November, 2015).

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 2015.

Tejas Patel,
Course Director,
TRICO 2014.



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