Proceedings of TRICO 2019 from desk of Tejas Patel


TRICO 2019, the 14th International Transradial Intervention Course was held on 1st and 2nd of February, this year. There was tremendous pressure on us to create 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 confirmed to join us, however because of the snowstorm in Japan, he missed his flight to Mumbai. This news added to our pressure because Dr. Saito has always been a master operator and demonstrator throughout all the TRICOs. Our old friends including Samir Pancholy, John Coppola, Tak Kwan, Rajiv Gulati, Ian Gilchrist, Tejan Patel, Fazila Malik, Surya Dharma and Mir Jamaluddin agreed to be on international guest faculty. Takashi Akasaka who is one of the world authorities on OCT and FFR also consented to join TRICO 2019. Our friend Mamas Mamas from UK also consented to join us. Md. Khalequzzaman, Md. Shafiqur Rahaman Patwary, Md. Anisujjaman Quazi and Md. Mamun Iqbal from Bangladesh were invited to be on international guest faculty.

This time, the venue was Nirma Auditorium at Nirma University campus, and the live transmission was from Apex Heart Institute, Ahmedabad. We accumulated 21 very complex cases of coronary and peripheral interventions and all of them got admitted on the 31th January, 2019, at Apex. 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 two weeks before TRICO 2019. We had to refuse several registrations because of non-availability of the seats in auditorium. Once again, there was a very heavy participation from Bangladesh (54 delegates). We had participation from several countries and 72 participants were from outside India. Sudan, Brazil and Indonesia were the new inclusions. Last moment dropout rate was 20%. Most participants and international guests arrived on 31st January, 2019. 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 and OCT imaging as well as demonstration of FFR and RFR.

On 1st February, 2019 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 XB 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 Xpedition 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 Ian Gilchrist also participated actively in the discussion with us and the panelists. The next case was having two type C lesions in RCA 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 38 mm long two Synergy stents 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 an in-stent critical stenosis of ostial LAD. Patient had complex arteria lusoria. Rajni assisted me for this case. We demonstrated the technique to enter ascending aorta through arteria lusoria. The cannulation of LMCA using a 6F XB guide catheter was tough. Everybody enjoyed this case. Dr. Akasaka and Ian Gilchrist gave excellent comments on the OCT imaging at the end. As patient had Everolimus eluting stent before, we used Orsiro (Sirolimus) stent. The final result was perfect. Before the second live demo, there was an excellent talk on utility of OCT, delivered by Rajiv Gulati of Mayo Clinic. Everybody enjoyed it.

The second live demo started with the fourth case: a multi vessel PCI and RCA origin was anomalous from LCC. Tak Kwan with Sanjay demonstrated this case. Tak very quickly finished stenting of LAD & LCX using Xience Xpedition and Promus Premier stents. He used the same XB 3.5 guide catheter to cannulate the anomalous RCA. He did it very elegantly. The RCA lesion was very calcified and he demonstrated the use of cutting balloon to crack the calcium and stented the lesion. He confirmed the results of all the lesions using IVUS imaging (Boston Scientific). Dr. Akasaka gave useful comments on IVUS imaging. The fifth case was a complex CTO of mid LAD at 90 degree angle and a critical RCA lesion. Rajni assisted me. We tried our level best using all our experience to cross the CTO but failed. There was an excellent discussion between the panelists and us. There was a lunch break for one hour.

We started our post-lunch session with two extremely important talks delivered by Vijay Kumar and Mamas Mamas which were very well received by the crowd. Following the talks, a live case of PCI of LMCA bifurcation stenosis was demonstrated by me and Sanjay. We wired LAD and LCX but after deploying the stent covering LMCA and proximal LAD there was minimal pinching of LCX ostium with normal flow. We confirmed the stent result using OCT imaging and did RFR of LCX ostial lesion which was 0.93, hence we did not stent LCX ostium. There was a great discussion between the panel, the onsite moderators (Rajiv Gulati and Samir Pancholy) and us. The next case was PCI of LAD thrombus containing lesion and a critical LCX lesion. Samir Pancholy with Rajni demonstrated how to deal with no reflow phenomenon using perforated balloon technique. It was an elegant demonstration. Samir used the IVUS imaging to confirm the end result. The next case was Robotic assisted multi vessel PCI done by me and Sanjay. Again the cassette preparation was demonstrated by Sanjay and Yash. I fixed all the three type-C lesions sitting in the cockpit. The end result was clean and everybody enjoyed. The last live demonstration case was a failed CTO PCI of LAD lesion done by me and Sanjay. Bilateral radial punctures were done. RCA was also cannulated to see the distal LAD segment filled by the collaterals. We used Fine-cross micro catheter (Terumo, Japan) and different CTO wires to cross the lesion but because of multiple false channels formation during previous PCI done elsewhere we were unable to cross the CTO. There was intense discussion bilaterally. 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 stenting of a near total complex left subclavian ostial stenosis. John Coppola was assisted by Sanjay. He is a very experienced radial operator and he did a good job to address this lesion through left TRA. It was difficult but he demonstrated it nicely. The second case was PCI of LMCA ostial and bifurcation stenosis done by me and Rajni. It generated great discussion at both ends. The result was confirmed by OCT imaging and Dr. Akasaka gave his masterly comments. The third case was an LCX OM stenosis PCI done by Tejan Patel with Sanjay. Tejan demonstrated mini-crush technique and did it nicely. The on-site moderators Fazila Malik, Surya Dharma and Takashi Akasaka actively participated in the discussion. The fourth case was a complex RCA CTO. I was assisted by Sanjay. We demonstrated the step-by-step the use of Fine-cross micro catheter for the wiring. It was really a tough case. At the end we were successful to do the endoluminal reconstruction using multiple stents with adequate end result. Following this case we showed another Robotic PCI of in-stent RCA lesion. We quickly finished the case and announced the lunch break.

After lunch, there were excellent talks delivered by Ian Gilchrist, Samir Pancholy, Surya Dharma and Wah Wah Htun. Following that there was discussion on several complex case presentations done by Sunil Gurmukhani, Saurabh Potdar, Pradyot Tiwari, Pooja, Hiren, Roopesh and Surya. At last, we had an interesting discussion on What is new in heart failure management?. The discussion was led by me and Samir Pancholy and participated by many. At 5:30 p.m. I concluded with vote of thanks and we officially ended TRICO 2019.

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 2020. Kindly note the dates for TRICO 2020. It is to be held on 8th and 9th of February, 2020. Hereby, I am doing by the most important announcement that this is the last dedicated transradial course. Henceforth, the course will retain the name TRICO but it is going to be a course of complex cardiovascular interventions, coronary imaging, physiology, robotic PCI and structural heart disease.
We are now shifting the gear!

Tejas Patel,
Course Director,
TRICO 2019.