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Aims Familial hypercholesterolemia (FH) is currently a worldwide health issue. Understanding the characteristics of patients is important for proper diagnosis and treatment. This study aimed to analyze the phenotypic and genetic features, including threshold cholesterol levels, of Korean patients with FH. Methods A total of 296 patients enrolled in the Korean FH registry were included, according to the following criteria: low-density lipoprotein-cholesterol (LDL-C) ＞190 mg/dL with tendon xanthoma or family history compatible with FH, or LDL-C ＞225 mg/dL. DNA sequences of three FH-associated genes were obtained using whole-exome or target exome sequencing. Threshold cholesterol levels for differentiating patients with FH/pathogenic variant (PV) carriers and predictors of PVs were identified. Results Of the 296 patients, 104 had PVs and showed more obvious clinical findings, including higher cholesterol levels. PV rates ranged from 30% to 64% when patients were categorized by possible or definite type according to the Simon Broome criteria. Frequent PV types included missense variants and copy number variations (CNVs), while the most frequent location of PVs was p.P685L in LDLR. The threshold LDL-C levels for patient differentiation and PV prediction were 177 and 225 mg/dL, respectively. Younger age, tendon xanthoma, and higher LDL-C levels were identified as independent predictors of PVs, while traditional cardiovascular risk factors were predictors of coronary artery disease. Conclusions Korean patients with FH had variable PV rates depending on diagnostic criteria and distinctive PV locations. The reported threshold LDL-C levels pave the way for efficient patient care in this population.

Aims The pressure increase per time unit (dP/dt) in aortic stenosis (AS) jet velocity is assumed to have inter-individual variability in the progressive AS stage. We sought to examine the association of aortic valve (AoV) Doppler-derived dP/dt in patients with mild to moderate AS with risk of progression to severe disease. Methods and results A total of 481 patients diagnosed with mild or moderate AS [peak aortic jet velocity (Vmax) between 2 and 4 m/s] according to echocardiographic criteria were included. AoV Doppler-derived dP/dt was determined by measuring the time needed for the pressure to increase at a velocity of the AoV jet from 1 m/s to 2 m/s. During a median follow-up period of 2.7 years, 12 of 404 (3%) patients progressed from mild to severe AS and 31 of 77 (40%) patients progressed from moderate to severe AS. AoV Doppler-derived dP/dt had a good ability to predict risk of progression to severe AS (area under the curve = 0.868) and the cut-off value was 600 mmHg/s. In multivariable logistic regression, initial AoV calcium score (adjusted odds ratio [aOR], 1.79; 95% confidence interval [CI], 1.18–2.73; P = 0.006) and AoV Doppler-derived dP/dt (aOR, 1.52/100 mmHg/s higher dP/dt; 95% CI, 1.10–2.05; P = 0.012) were associated with progression to severe AS. Conclusion AoV Doppler-derived dP/dt above 600 mmHg/s was associated with risk of AS progression to the severe stage in patients with mild to moderate AS. This may be useful in individualized surveillance strategies for AS progression.

Background: It remains unclear whether P2Y 12 monotherapy, especially clopidogrel, following short-duration dual antiplatelet therapy (DAPT) is associated with favorable outcomes in patients undergoing complex percutaneous coronary intervention (PCI). Therefore, this study analyzed the efficacy and safety of P2Y 12 inhibitor monotherapy, mostly clopidogrel (78%), in complex PCI following short-term DAPT. Methods: The post-hoc analysis of the SMART-CHOICE trial involving 2,993 patients included 498 cases of complex PCIs, defined by at least one of the following features: 3 vessels treated, ≥ 3 stents implanted, ≥ 3 lesions treated, bifurcation with ≥ 2 stents implanted, and a total stent length of ≥ 60 mm. The primary endpoint was major adverse cardiac and cerebrovascular event (MACCE), defined as the composite of all-cause death, myocardial infarction, and stroke. The primary safety endpoint included bleeding, defined as Bleeding Academic Research Consortium (BARC) types 2 to 5. Results: Complex PCI group had a higher risk of MACCE (4.0% vs. 2.3%, hazard ratio [HR] = 1.74, 95% confidence interval [CI]: 1.05–2.89, p = 0.033) and a similar risk of BARC types 2–5 bleeding (2.6% vs. 2.6%, HR = 1.02, 95% CI: 0.56–1.86, p = 0.939) compared with those without complex PCIs. Patients undergoing complex PCIs, followed by P2Y 12 inhibitor monotherapy and 12 months of DAPT exhibited similar rates of MACCE (3.8% vs. 4.2%, HR = 0.92, 95% CI: 0.38–2.21, p = 0.853). Conclusions: P2Y 12 inhibitor monotherapy, mostly clopidogrel, following 3 months of DAPT did not increase ischemic events in patients with complex PCIs.

Summary Background In patients with acute myocardial infarction receiving potent antiplatelet therapy, the bleeding risk remains high during the maintenance phase. We sought data on a uniform unguided de-escalation strategy of dual antiplatelet therapy (DAPT) from ticagrelor to clopidogrel after acute myocardial infarction. Methods In this open-label, assessor-masked, multicentre, non-inferiority, randomised trial (TALOS-AMI), patients at 32 institutes in South Korea with acute myocardial infarction receiving aspirin and ticagrelor without major ischaemic or bleeding events during the first month after index percutaneous coronary intervention (PCI) were randomly assigned in a 1:1 ratio to a de-escalation (clopidogrel plus aspirin) or active control (ticagrelor plus aspirin) group. Unguided de-escalation without a loading dose of clopidogrel was adopted when switching from ticagrelor to clopidogrel. The primary endpoint was a composite of cardiovascular death, myocardial infarction, stroke, or bleeding type 2, 3, or 5 according to Bleeding Academic Research Consortium (BARC) criteria from 1 to 12 months. A non-inferiority test was done to assess the safety and efficacy of de-escalation DAPT compared with standard treatment. The hazard ratio (HR) for de-escalation versus active control group in a stratified Cox proportional hazards model was assessed for non-inferiority by means of an HR margin of 1·34, which equates to an absolute difference of 3·0% in the intention-to-treat population and, if significant, a superiority test was done subsequently. To ensure statistical robustness, additional analyses were also done in the per-protocol population. This trial is registered at ClinicalTrials.gov, NCT02018055. Findings From Feb 26, 2014, to Dec 31, 2018, from 2901 patients screened, 2697 patients were randomly assigned: 1349 patients to de-escalation and 1348 to active control groups. At 12 months, the primary endpoints occurred in 59 (4·6%) in the de-escalation group and 104 (8·2%) patients in the active control group (pnon-inferiority Interpretation In stabilised patients with acute myocardial infarction after index PCI, a uniform unguided de-escalation strategy significantly reduced the risk of net clinical events up to 12 months, mainly by reducing the bleeding events. Funding ChongKunDang Pharm, Medtronic, Abbott, and Boston Scientific.

BACKGROUND Clopidogrel is a platelet aggregation inhibitor used for the management of cardiovascular disease. While antiplatelet therapy decreases cardiovascular events after successful coronary drug-eluting stenting, it increases the risk of gastrointestinal (GI) bleeding. About 20% of the patients who take clopidogrel exhibit resistance to the drug. CASE SUMMARY We report the first case of a small bowel bleeding ulcer in an 86-year-old man with clopidogrel resistance. He had a history of taking clopidogrel due to unstable angina. There was no evidence of bleeding in the stomach, duodenum, or colon through upper and lower GI endoscopies. The abdominal computed tomography showed the extravasation of radiocontrast media at the ileum. Because of unstable vital signs, emergency surgery was performed. Multiple ulcers with inflammation were found in the ileum. The pathologic findings revealed simple inflammation. The VerifyNow P2Y12 test showed clopidogrel resistance. One year after changing to aspirin, capsule endoscopy was performed and the small bowel ulcers were improved. CONCLUSION Small bowel ulcers and bleeding due to clopidogrel are not very common, but the prevalence is expected to increase in older age patients with risk factors despite clopidogrel resistance.

Among patients undergoing percutaneous coronary procedures, transradial access, compared with transfemoral access, is associated with a reduced risk for complications including mortality, especially in higher risk patients. However, transradial access is limited by radial artery occlusion (RAO) that despite being mostly asymptomatic because of the extensive anastomoses between the forearm arteries restricts future use of the same radial artery. Distal radial access (DRA) in the anatomic snuffbox or on the dorsum of the hand has recently gained global popularity as an alternative access route for vascular procedures. A strong anatomic and physiological rationale yields potential for significantly reduced risk for RAO and positive impact on procedural outcome for better patient care. Indeed, currently published studies buttress very low rates of RAO after DRA, hence supporting its development. The authors provide an analysis of the foundation of DRA, provide historical background, and offer a critical review of its current status and future directions. Also, given the limited evidence currently available to properly perform DRA in the real world, consensus opinion on what is considered optimal practice is also presented to supplement this document and enhance the implementation of DRA while minimizing its complications.

ObjectiveTo compare P2Y12 inhibitor monotherapy after 3-month dual antiplatelet therapy (DAPT) with 12-month DAPT according to the type of P2Y12 inhibitor in patients undergoing percutaneous coronary intervention (PCI).MethodsThe Smart Angioplasty Research Team: Comparison Between P2Y12 Antagonist Monotherapy vs Dual Antiplatelet Therapy in Patients Undergoing Implantation of Coronary Drug-Eluting Stents (SMART-CHOICE) randomised trial compared 3-month DAPT followed by P2Y12 inhibitor monotherapy with 12-month DAPT. In this trial, 2993 patients undergoing successful PCI with drug-eluting stent were enrolled in Korea. As a prespecified analysis, P2Y12 inhibitor monotherapy after 3-month DAPT versus 12-month DAPT were compared among patients receiving clopidogrel and those receiving potent P2Y12 inhibitor (ticagrelor or prasugrel), respectively. The primary endpoint was a composite of all-cause death, myocardial infarction or stroke at 12 months after the index procedure.ResultsAmong 2993 patients (mean age 64 years), 58.2% presented with acute coronary syndrome. Clopidogrel was prescribed in 2312 patients (77.2%) and a potent P2Y12 inhibitor in 681 (22.8%). There were no significant differences in the primary endpoint between the P2Y12 inhibitor monotherapy group and the DAPT group among patients receiving clopidogrel (3.0% vs 3.0%; HR: 1.02; 95% CI 0.64 to 1.65; p=0.93) as well as among patients receiving potent P2Y12 inhibitors (2.4% vs 0.7%; HR: 3.37; 95% CI 0.77 to 14.78; p=0.11; interaction p=0.1). Among patients receiving clopidogrel, P2Y12 inhibitor monotherapy compared with DAPT showed consistent treatment effects across various subgroups for the primary endpoint. Among patients receiving potent P2Y12 inhibitors, the rate of bleeding (Bleeding Academic Research Consortium types 2– 5) was significantly lower in the P2Y12 inhibitor monotherapy group than in the DAPT group (1.5% vs 5.0%; HR: 0.33; 95% CI 0.12 to 0.87; p=0.03).ConclusionsCompared with 12-month DAPT, clopidogrel monotherapy after 3-month DAPT showed comparable cardiovascular outcomes in patients undergoing PCI.Trial registration numberNCT02079194.

Background. Total ischemic time (TIT) is an important factor for predicting mortality among patients with ST-segment elevation myocardial infarction (STEMI). However, the correlation between TIT and the extent of wall motion abnormality has not been well studied. Therefore, we investigated changes in the wall motion score index (WMSI) value based on TIT in STEMI patients who underwent primary percutaneous coronary intervention (PCI) and subsequent transthoracic echocardiography. Methods. STEMI patients who underwent primary PCI and follow-up coronary angiography were analyzed after the exclusion of cases of in-stent restenosis (ISR). WMSI values were calculated by dividing the sum of scores by the number of segments visualized. Results. A total of 189 patients underwent primary PCI for STEMI, and 151 had no ISR with a median follow-up of 12.3 months. TIT was 180 (117–369) minutes in a subset of 151 patients (mean age of 62 years; 76% male). Among patients without ISR, 109 (72%) demonstrated a decrease in the WMSI value during the follow-up period. The WMSI values of patients with TITs of 180 minutes or less were significantly decreased relative to those among patients with TITs of greater than 180 minutes ( p = 0.020 ). Among patients with TITs of 180 minutes or less, the TIT was significantly shorter among those with a reduction in the WMSI value than among those with an increase in the WMSI value (106 [81–124] vs. 133 [100–151] minutes; p = 0.018 ). TIT was an independent predictor for a reduction in the WMSI value among these patients (adjusted hazard ratio: 0.976 (0.957–0.995); p = 0.016 ). Conclusions. In the modern reperfusion era of STEMI, patients with TITs of 180 minutes or less experienced a significant degree of recovery from regional wall motion abnormalities.

ImportanceAlthough P2Y12 inhibitor monotherapy after a minimum period of dual antiplatelet therapy (DAPT) is a well-known way to reduce the risk of bleeding after percutaneous coronary intervention (PCI), data comparing long-term clinical outcomes between P2Y12 inhibitor monotherapy and extended DAPT in patients undergoing PCI have been unavailable.ObjectiveTo identify the long-term safety and efficacy of P2Y12 inhibitor monotherapy following 3 months of DAPT after PCI.Design, Setting, and ParticipantsThe Smart Angioplasty Research Team: Comparison Between P2Y12 Antagonist Monotherapy and Dual Antiplatelet Therapy in Patients Undergoing Implantation of Coronary Drug-Eluting Stents (SMART-CHOICE) trial was an open-label, noninferiority, randomized clinical trial, enrolling patients who underwent PCI with drug-eluting stent at 33 hospitals in Korea from March 2014 through July 2017. Clinical follow-up was extended to 3 years and completed in August 2020.InterventionsPatients were randomly assigned to either P2Y12 inhibitor monotherapy after 3 months of DAPT or DAPT for 12 months or longer.Main Outcomes and MeasuresThe primary end point was major adverse cardiac and cerebrovascular events (a composite of all-cause death, myocardial infarction, or stroke) at 3 years. The secondary end points included the components of the primary end point, bleeding (defined as Bleeding Academic Research Consortium [BARC] types 2-5), and major bleeding (BARC types 3-5).ResultsIn total, 2993 patients were randomly assigned to receive P2Y12 inhibitor monotherapy after 3 months of DAPT (1495 patients [50%]; mean [SD] age, 64.6 [10.7] years; 1087 [72.7%] male) or prolonged DAPT (1498 patients [50%]; mean [SD] age, 64.6 [10.7] years; 1111 [74.2%] male) after PCI. At 3 years, the primary end point occurred in 87 individuals (6.3%) in the P2Y12 inhibitor monotherapy group and 83 (6.1%) in the prolonged DAPT group (hazard ratio [HR], 1.06 [95% CI, 0.79-1.44]; P = .69). P2Y12 inhibitor monotherapy significantly reduced the risk of bleeding (BARC types 2-5: 112 [3.2%] vs 44 [8.2%]; HR, 0.39 [95% CI, 0.28-0.55]; P P = .048), compared with prolonged DAPT. The landmark analyses between 3 months and 3 years and per-protocol analyses showed consistent results.Conclusions and RelevanceAmong patients who underwent PCI and completed 3-month DAPT, P2Y12 inhibitor monotherapy was associated with a lower risk of clinically relevant major bleeding than prolonged DAPT. Although the 3-year risk of ischemic cardiovascular events was comparable between the 2 groups, this result should be interpreted with caution owing to the limited number of events and sample size.Trial RegistrationClinicalTrials.gov Identifier: NCT02079194

Cardiac angiography to visualize the cardiac coronary artery for lesions causes a lot of radiation exposure dose to the interventional cardiologist. We evaluated the occupational radiation exposure to the interventional cardiologist based on changes to the angle of the X-ray tube used in cardiac angiography and calculated the conversion factor for effective dose in this study. To evaluate the occupational radiation exposure resulting from scattered radiation to interventional cardiologists, organ doses for eyeball, thyroid, and heart were calculated using Monte Carlo simulation with korean typical man(KTMAN) phantom at the left anterior oblique (LAO)30/cranial (CRAN)30, CRAN40, right anterior oblique (RAO)30/CRAN30, RAO30/caudal(CAUD)20, CAUD39, LAO40/CAUD35, and LAO40 positions in the femoral and the radial artery puncture. In this study, analysis of the different angles showed the highest radiation exposure on LAO30/CRAN30 and CRAN40 position, which were 150.65% and 135.3%, respectively, compared to AP angles. Therefore, to reduce occupational dose for interventional cardiologists, it is recommended that radiation protection, such as using radiation shield and personal protective equipment (PPE), be used at LAO30/CRAN30 and CRAN40 angulation, and the conversion factor for calculating the organ dose received by the interventional cardiologists based on patient dose can be applied for improved occupational dose management.

Background and objectives Intermediate coronary lesion that can be under- or over-estimated by visual estimation frequently results in stenting of functionally nonsignificant lesions or deferral of percutaneous coronary intervention (PCI) of significant lesions inappropriately. We evaluated current status of PCI for intermediate lesions from a standardized database in Korea. Methods We analyzed the Korean percutaneous coronary intervention (K-PCI) registry data which collected a standardized PCI database of the participating hospitals throughout the country from January 1, 2014, through December 31, 2014. Intermediate lesion was defined as a luminal narrowing between 50% and 70% by visual estimation and then compared whether the invasive physiologic or imaging study was performed or not. Results Physiology-guided PCI for intermediate lesions was performed in 16.8% for left anterior descending artery (LAD), 9.8% for left circumflex artery (LCX), 13.2% for right coronary artery (RCA). PCI was more frequently performed using intravascular ultrasound (IVUS) than using fractional flow reserve (FFR) for coronary artery segments (27.7% vs. 13.9% for LAD, 32.9% vs. 8.1% for LCX, and 33.8% vs. 10.8% for RCA). In accordance with or without FFR, PCI for intermediate lesions was more frequently performed in the hospitals with available FFR device than without FFR, especially in left main artery (LM), proximal LAD lesion (40.9% vs. 5.9% for LM, 24.6% vs 7.6% for proximal LAD). Conclusions These data provide the current PCI practice pattern with the use of FFR and IVUS in intermediate lesion. More common use of FFR for intermediate lesion should be encouraged.

Introduction Although the implementation of transradial intervention (TRI) has increased over the last few years, there are limited data on the impact of TRI on efficacy and safety in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS). We sought to compare one-year clinical outcomes and bleeding complications of TRI with those of transfemoral intervention (TFI) in patients with NSTE-ACS. Methods The Korean TRI registry was a cohort of 20 centres from 2012 to 2015. The primary efficacy endpoint was major adverse cardiovascular events (MACE), defined as a composite of cardiac death (CD), non-fatal myocardial infarction (MI) and repeat revascularisation (RR). Among the 1 319 patients with NSTE-ACS, 1 285 were finally analysed after excluding 34 due to lack of follow-up data. The patients were divided into TRI and TFI groups according to the final access site. Results At one-year follow up, the TRI group showed a significantly lower rate of MACE, and a marginally significantly lower rate of CD than the TFI group in the crude population. However, in propensity-score matched analysis, the rate of MACE did not differ between the TRI and TFI groups. Regarding bleeding complications, the TRI group was associated with significantly lower rates of major bleeding in both the crude and matched populations. Independent predictors of MACE were chronic kidney disease (CKD) and multi-vessel disease (MVD). Conclusions In patients with NSTE-ACS, TRI was associated with favourable one-year clinical outcomes and lower bleeding complications compared to TFI. Independent predictors of MACE were clinical and angiographic profiles (CKD, MVD) rather than vascular access sites.

BACKGROUND Statins are thought to have little effect on the progression of aortic stenosis, but the data on their role in patients with aortic valve sclerosis (AVS) are limited and inconsistent. METHODS We retrospectively analyzed 541 consecutive patients (214 men, age: 70 ± 11 years) with AVS. Each patient underwent two or more electrocardiography examinations at least 6 months apart at Kangwon National University Hospital from August 2010 to August 2015. AVS is defined as irregular thickening of the leaflets, focal increases in echogenicity and minimal elevation of the peak aortic valve velocity (> 1.5 and < 2 m/s). The progression rate of AVS was expressed as the increase in peak velocity per year (m/s/yr). RESULTS The mean follow-up duration was 24.9 ± 13.3 months in the statin-treated group and 24.1 ± 12.4 months in the non-statin-treated group (p = 0.460). There were no differences between the statin-treated and non-statin-treated groups in mean age, gender or smoking status. Relative to the non-statin-treated group, a higher number of patients in the statin-treated group had hypertension, diabetes, ischemic heart disease, and stroke. The progression rate of AVS did not differ between the statin-treated and non-statin-treated groups (0.012 ± 0.340 m/s/yr vs. 0.014 ± 0.245 m/s/yr, p = 0.956). Multivariate analysis showed initial peak aortic jet velocity was significantly associated with AVS progression (β = 0.153, p = 0.009). CONCLUSIONS Our study demonstrated that statins had no effect on the progression of AVS. However, well-designed studies are needed to define the prognosis and management of AVS.

Among the 146 patients enrolled in the Korean FH registry, 83 patients who had undergone appropriate LLT escalation and were followed-up for ≥ 6 months were analyzed for pathogenic variants (PVs). The achieved percentage of expected low-density lipoprotein-cholesterol (LDL-C) reduction (primary variable) and achievement rates of LDL-C 2 = 0.045, p = 0.048). Among evolocumab users, PV-negative patients or those with only defective PVs revealed higher primary variable, whereas patients with at least one null PV showed lower primary variables. The adjusted response of patients with FH to LLT showed significant associations with PV positivity and 4-SNP score. These results may be helpful in managing FH patients with diverse genetic backgrounds.

Among patients undergoing percutaneous coronary procedures, transradial access, compared with transfemoral access, is associated with a reduced risk for complications including mortality, especially in higher risk patients. However, transradial access is limited by radial artery occlusion (RAO) that despite being mostly asymptomatic because of the extensive anastomoses between the forearm arteries restricts future use of the same radial artery. Distal radial access (DRA) in the anatomic snuffbox or on the dorsum of the hand has recently gained global popularity as an alternative access route for vascular procedures. A strong anatomic and physiological rationale yields potential for significantly reduced risk for RAO and positive impact on procedural outcome for better patient care. Indeed, currently published studies buttress very low rates of RAO after DRA, hence supporting its development. The authors provide an analysis of the foundation of DRA, provide historical background, and offer a critical review of its current status and future directions. Also, given the limited evidence currently available to properly perform DRA in the real world, consensus opinion on what is considered optimal practice is also presented to supplement this document and enhance the implementation of DRA while minimizing its complications.

During interventional cardiological procedures, operators are exposed to patients’ scatter radiation. Therefore, we measured the radiation exposure of the operator’s eyeball, thyroid, and chest wall during angiography. We used the optically stimulated luminescence dosimeter in the anthropomorphic phantom and developed Monte Carlo simulations using the Korean human voxel phantom. At 15 frames/s, the radiation dose of the operator’s right eyeball (RE), left eyeball (LE), thyroid (T), and chest wall (CW) at the femoral artery puncture position (FAPP) with protective equipment (PE) was 0.015, 0.16, 0.012, and 0.014 mGy, respectively. At 7.5 frames/sec, the radiation dose of the operator’s RE, LE, T, and CW at FAPP with PE was 33.33%, 18.75%, 52.94%, and 45.00% lower than that of those at the radial artery puncture position (RAPP), respectively. At 15 frames/s, the radiation dose of the operator’s RE, LE, T, and CW at RAPP without PE was 1.76 times, 2.23 times, 2.76 times, and 2.05 times higher than that of those with PE. Per the simulation results, the absorbed radiation dose of the eye ball, thyroid gland, and myocardium of the heart at FAPP with and without PE under 15 frame/s was 9.68%, 13.04%, 8.33% and 9.98%, 6.00%, 8.82% lower than at RAPP under similar conditions. Effective measures for occupational radiological protection are lower frame rate exposure, increased distance from the X-ray source, and PE use. Radiologist protection in interventional cardiology cannot be handled independently of patient protection, owing to several correlations; thus, reducing the patient dose will reduce the operator dose.

Medical radiation exposure is a significant concern for interventional cardiologists (IC). This study was aimed at estimating the radiation exposure of IC operators and assistants in real clinical practice. The radiation exposure of the operator and assistant was evaluated by conducting two types of procedures via coronary angiography (CAG) and percutaneous coronary intervention (PCI) on 1090 patients in 11-cardiovascular centers in Korea. Radiation exposure was measured using an electronic personal dosimeter (EPD). EPD were attached at 3 points on each participant: on the apron on the left anterior chest (A1), under the apron on the sternum (A2), and on the thyroid shield (T). Average radiation exposure (ARE) of operators at A1, A2, and T was 19.219 uSv, 4.398 uSv, and 16.949 uSv during CAG and 68.618 uSv, 15.213 uSv, and 51.197 uSv during PCI, respectively. ARE of assistants at A1, A2, and T was 4.941 uSv, 0.860 uSv, and 5.232 uSv during CAG and 20.517 uSv, 4.455 uSv, and 16.109 uSv during PCI, respectively. AED of operator was 3.4 times greater during PCI than during CAG.

Background/aims Transradial intervention (TRI) is becoming the preferred method over transfemoral intervention (TFI) because TRI is associated with lower incidence of major bleeding and vascular complications. However, there has been limited published data regarding the clinical outcomes of TRI versus TFI in Korean patients with ST-elevation myocardial infarction (STEMI). Methods A total of 689 consecutive STEMI patients who underwent primary percutaneous coronary intervention (PCI) with drug-eluting stents (DESs) from January to December of 2009 at nine university hospitals were enrolled in this study. Mid-term angiographic and 12-month cumulative clinical outcomes of the TRI group (n = 220, 31.9%) were compared to those of the TFI group (n = 469, 28.1%). Results After propensity score matching, in-hospital complications and the 12-month major clinical outcomes during follow-up in the two groups were similar to each other. However, the incidence rates of repeat revascularization (6.4% vs. 0.5%, p = 0.003), target vessel revascularization (6.4% vs. 0.5%, p = 0.003), and major adverse cardiac events (MACE; 11.6% vs. 4.6%, p = 0.018) in the TFI group were higher than those in the TRI group during the 12-month of follow-up. Conclusions In our study, TRI in STEMI patients undergoing primary PCI with DESs was associated with lower incidence of access site hematoma, 12-month repeat revascularization, and MACE compared to TFI. Therefore, TRI might play an important role in reducing bleeding complications while improving major clinical outcomes in STEMI patients undergoing primary PCI with DESs.

Background Simplicity of regimen is known to be an important determinant of medication adherence and using single-pill combination (SPC) in hypertension treatment resulted in better adherence and persistence than free-equivalent combination. However, this finding has been studied only in dual-component antihypertensive treatments and in observational studies using medication possession ratio as an index of adherence. Medication event monitoring system (MEMS) is considered to be the gold standard in estimating medication adherence. Purpose To investigate the superiority in adherence of triple-component SPC compared to equivalent two-pill regimen using MEMS Methods This is a multi-center open-label randomized controlled trial. Inclusion criteria were hypertensive patients whose clinic blood pressure is not adequately controlled (systolic >140 mmHg or diastolic >90 mmHg) with combination antihypertensive regimen comprising two of three classes (angiotensin receptor blocker, calcium channel blocker and thiazide diuretics) for at least 4 weeks. Eligible patients were randomized either to single-pill (triple-component SPC, olmesartan/amlodipine/ hydrochlorothiazide 20/5/12.5 mg) or two-pill (dual-component SPC + one free pill, olmesartan/hydrochlorothiazide 20/12.5 mg + amlodipine 5 mg) groups and maintained for 12 weeks. Medications were dispensed in MEMS. Primary outcomes were the difference of percentage of dose taken (PDT) and percentage of days with prescribed dose taken correctly (PDTc) between single- and two-pill therapy, calculated from MEMS data. Results From 8 hospitals, 146 hypertensive patients were randomized into single- and two-pill groups. Final analysis was done in 65 and 66 patients in each group from which adherence index could be obtained. Baseline clinical characteristics of the two groups were not different. The single-pill group had significantly higher PDT and PDTc compared to the two-pill group. (median (25–75 percentile) (%), PDT 95.1 (87.9 - 100.0) vs 91.2 (79.8 - 96.5); PDTc 93.1 (79.8 - 96.5) vs 91.3 (70.7 - 96.4), p = both 0.04, by Wilcoxon rank sum test) Percent dose taken Conclusion Single-pill combination of triple-component antihypertensive regimen showed superior adherence compared to equivalent two-pill therapy. Reducing pill burden by using SPC is a relevant strategy to enhance the adherence to multi-drug antihypertensive therapy. Acknowledgement/Funding Daiichi-Sankyo

BACKGROUND: Data on treatment results of lipid‐lowering therapy (LLT) in familial hypercholesterolemia (FH) are limited, particularly in Asian patients. HYPOTHESIS: We sought to evaluate the target achievement rate and associated variables in Korean patients with FH after maximal statin‐based LLT. METHODS: We enrolled 146 patients with heterozygous FH, and 90 patients were finally analyzed. Patients were initially prescribed rosuvastatin 10 mg or atorvastatin 20 mg, and the regimen was adjusted to achieve the low‐density lipoprotein cholesterol (LDL‐C) target of 100 mg/dL. The primary evaluation point was the achievement rate of the LDL‐C targets at 12 months: LDL‐C < 100 mg/dL and ≥50% LDL‐C reduction. The associations between clinical variables and target achievement were also analyzed. RESULTS: At 12 months, 58% of patients were receiving high‐intensity regimens, whereas 46% were receiving combination therapy. The mean pre‐ and post‐treatment LDL‐C levels were 229 and 118 mg/dL, respectively. Twenty‐eight percent of patients achieved LDL‐C < 100 mg/dL, and 47% achieved ≥50% LDL‐C reduction. Pretreatment LDL‐C and high‐intensity regimens indicated a negative tendency toward the attainment of LDL‐C < 100 mg/dL. Conversely, pretreatment LDL‐C and diabetes mellitus were positively associated with a higher rate of ≥50% LDL‐C reduction. CONCLUSIONS: The target achievement of LDL‐C < 100 mg/dL was low, and 50% LDL‐C reduction was moderately achieved in Korean patients with FH receiving maximal statin‐based LLT. Pretreatment LDL‐C levels and diabetes mellitus were associated with target achievement. Our results provide rare and informative data on FH treatment in Asian patients.

Interventional cardiology procedures can involve relatively high radiation doses compared to general radiography. During coronary angiography (CAG) and percutaneous transluminal coronary intervention (PCI), the same area is exposed to radiation for a long period. In this study, radiation exposure data of 1071 examinations in Korean hospitals were collected, and the achievable dose (AD) and diagnostic reference levels (DRLs) in actual medical practice for two types of interventional cardiology procedures in Korea were established. In CAG, 75th percentile DRLs and AD of the total kerma-area product were 47.0 and 33.1 Gy·cm 2, respectively. In PCI, those values were 171.3 and 102.6 Gy·cm2, respectively. This is the first study to introduce the DRLs for cardiovascular interventional procedures in Korea. These results will help optimise the interventional cardiology procedures for Korean cardiac centres.

The transradial approach is increasingly used for percutaneous coronary intervention (PCI), and we therefore aimed to compare the clinical outcomes after transradial intervention (TRI) and transfemoral intervention (TFI) in all patients undergoing PCI. Among 6,973 patients enrolled in a nationwide, prospective, multicenter registry (February 2013 to September 2013), 1,860 underwent TRI (n = 1,445, 77.7%) and TFI (n = 415, 22.3%). Bleeding and major adverse cardiac events (MACE; death, myocardial infarction, revascularization, or stent thrombosis) were compared. Bleeding occurred in 42 patients (2.3%) and was significantly less likely in the TRI versus TFI group (overall cohort: 1.5% vs 4.8%, p = 0.001; propensity score-matched: n = 728, 2.7% vs 5.2%, p = 0.048). Multivariate regression revealed that TRI was negatively associated with bleeding (odds ratio 0.42, 95% CI 0.21 to 0.83, p = 0.013). MACE occurred in 152 patients (8.2%). Kaplan-Meier estimates showed higher MACE-free survival rates in the TRI versus TFI group (overall cohort: 93.3% vs 86.7%, log-rank p = 0.026; propensity score-matched: 91.8% vs 86.5%, log-rank p = 0.04). Cox proportional analysis demonstrated that TRI independently predicted improved MACE (hazard ratio 0.64, 95% CI 0.43 to 0.91, p = 0.024). In conclusion, TRI is associated with reduced bleeding rates and better clinical outcomes than TFI in all patients undergoing PCI.

심장혈관 조영술과 인터벤션은 현대 성인병의 증가로 급격히 증가하고 있다. 심장혈관 인터벤션은 장시간 동일 부위에 방사선을 조사하는 검사로 방사선으로 인한 피부상해를 일으킬 수 있다. 본 연구에서는 의료기관의 심장혈관 인터벤션의 진단참조준위를 조사하여 환자의 피폭선량을 감소시키는 도구로 사용하고자 한다. 본 연구는 147명의 환자에서 심장혈관 조영술과...

Background and Objectives When monotherapy is inadequate for blood pressure control, the next step is either to continue monotherapy in increased doses or to add another antihypertensive agent. However, direct comparison of double-dose monotherapy versus combination therapy has rarely been done. The objective of this study is to compare 10 mg of amlodipine with an amlodipine/valsartan 5/160 mg combination in patients whose blood pressure control is inadequate with amlodipine 5 mg. Subjects and Methods This study was conducted as a multicenter, open-label, randomized controlled trial. Men and women aged 20-80 who were diagnosed as having hypertension, who had been on amlodipine 5 mg monotherapy for at least 4 weeks, and whose daytime mean systolic blood pressure (SBP) ≥135 mmHg or diastolic blood pressure (DBP) ≥85 mmHg on 24-hour ambulatory blood pressure monitoring (ABPM) were randomized to amlodipine (A) 10 mg or amlodipine/valsartan (AV) 5/160 mg group. Follow-up 24-hour ABPM was done at 8 weeks after randomization. Results Baseline clinical characteristics did not differ between the 2 groups. Ambulatory blood pressure reduction was significantly greater in the AV group compared with the A group (daytime mean SBP change: -14±11 vs. -9±9 mmHg, p

Intermediate coronary lesions that can be under- or overestimated by visual estimation frequently result in stenting of functionally nonsignificant lesions or deferral of percutaneous coronary intervention (PCI) of significant lesions inappropriately. We evaluated the current status of PCI for

Therapeutic angiogenesis has achieved promising results for ischemic diseases or peripheral artery disease in preclinical and early-phase clinical studies. We examined the therapeutic angiogenic effects of HPOX, which is biodegradable polymer composing the antioxidant p -hydroxybenzyl alcohol (HBA), in a mouse model of hindlimb ischemia. HPOX effectively stimulated blood flow recovery, compared with its degraded compounds HBA and 1,4-cyclohexendimethanol, via promotion of capillary vessel density in the ischemic hindlimb. These effects were highly correlated with levels of angiogenic inducers, vascular endothelial cell growth factor (VEGF), heme oxygenase-1 (HO-1), and Akt/AMPK/endothelial nitric oxide synthase (eNOS) in ischemic mouse hindlimb muscle. Blood perfusion and neovascularization induced by HPOX were reduced in eNOS −/− and HO-1 +/− mice. HPOX also elevated the endothelial cell markers VEGF receptor-2, CD31, and eNOS mRNAs in the ischemic hindlimb, indicating that HPOX increases endothelial cell population and angiogenesis in the ischemic muscle. However, this nanoparticle suppressed expression levels of several inflammatory genes in ischemic tissues. These results suggest that HPOX significantly promotes angiogenesis and blood flow perfusion in the ischemic mouse hindlimb via increased angiogenic inducers, along with suppression of inflammatory gene expression. Thus, HPOX can be used potentially as a noninvasive drug intervention to facilitate therapeutic angiogenesis.

Aims: Hypoxia induces expression of various genes and microRNAs (miRs) that regulate angiogenesis and vascular function. In this study, we investigated a new functional role of new hypoxia-responsive miR-101 in angiogenesis and its underlying mechanism for regulating heme oxygenase-1 (HO-1) and vascular endothelial growth factor (VEGF) expression. Results: We found that hypoxia induced miR-101, which binds to the 3′untranslated region of cullin 3 (Cul3) and stabilizes nuclear factor erythroid-derived 2-related factor 2 (Nrf2) via inhibition of the proteasomal degradation pathway. miR-101 overexpression promoted Nrf2 nuclear accumulation, which was accompanied with increases in HO-1 induction, VEGF expression, and endothelial nitric oxide synthase (eNOS)-derived nitric oxide (NO) production. The elevated NO-induced S-nitrosylation of Kelch-like ECH-associated protein 1 and subsequent induction of Nrf2-dependent HO-1 lead to further elevation of VEGF production via a positive feedback loop between the Nrf2/HO-1 and VEGF/eNOS axes. Moreover, miR-101 promoted angiogenic signals and angiogenesis both in vitro and in vivo, and these events were attenuated by inhibiting the biological activity of HO-1, VEGF, or eNOS. Moreover, these effects were also observed in aortic rings from HO-1+/− and eNOS−/− mice. Local overexpression of miR-101 improved therapeutic angiogenesis and perfusion recovery in the ischemic mouse hindlimb, whereas antagomiR-101 diminished regional blood flow. Innovation: Hypoxia-responsive miR-101 stimulates angiogenesis by activating the HO-1/VEGF/eNOS axis via Cul3 targeting. Thus, miR-101 is a novel angiomir. Conclusion: Our results provide new mechanistic insights into a functional role of miR-101 as a potential therapeutic target in angiogenesis and vascular remodeling. Antioxid. Redox Signal. 21, 2469–2482.

Background and rationale Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor reduces thrombotic events in patients undergoing percutaneous coronary intervention (PCI), but these benefits come at the expense of increased risk of bleeding when compared with aspirin monotherapy. It is unclear whether P2Y12 inhibitor monotherapy might maintain anti-ischemic efficacy while reducing the bleeding risk compared with DAPT after implantation of the current generation of drug-eluting stents (DES). Study design The SMART-CHOICE trial is a prospective, open-label, multi-center, and randomized study designed to test the non-inferiority of P2Y12 inhibitor monotherapy compared with aspirin plus a P2Y12 inhibitor after mandatory 3-month DAPT in patients undergoing PCI with current-generation DES. A total of 3000 patients will be randomized to 1 of the 2 antiplatelet treatment strategy groups. Randomization will be stratified by stent type (cobalt-chromium everolimus-eluting stents, platinum-chromium everolimus-eluting stents, and sirolimus-eluting stents with bioresorbable polymer), P2Y12 inhibitors (clopidogrel, prasugrel, and ticagrelor), clinical presentation (acute coronary syndrome and stable ischemic heart disease), and investigational centers. The primary end point is a composite of all-cause death, myocardial infarction, and cerebrovascular events at 12 months after the index procedure. The key secondary end points are definite/probable stent thrombosis defined by the Academic Research Consortium, and bleeding defined by Bleeding Academic Research Consortium type 2–5. Conclusions The SMART-CHOICE trial aims to examine the non-inferiority of monotherapy with one of any available oral P2Y12 inhibitors versus conventional DAPT of an identical P2Y12 inhibitor plus aspirin in a broad spectrum of patients receiving representative current-generation DES.

Importance Data on P2Y12 inhibitor monotherapy after short-duration dual antiplatelet therapy (DAPT) in patients undergoing percutaneous coronary intervention are limited. Objective To determine whether P2Y12 inhibitor monotherapy after 3 months of DAPT is noninferior to 12 months of DAPT in patients undergoing PCI. Design, Setting, and Participants The SMART-CHOICE trial was an open-label, noninferiority, randomized study that was conducted in 33 hospitals in Korea and included 2993 patients undergoing PCI with drug-eluting stents. Enrollment began March 18, 2014, and follow-up was completed July 19, 2018. Interventions Patients were randomly assigned to receive aspirin plus a P2Y12 inhibitor for 3 months and thereafter P2Y12 inhibitor alone (n = 1495) or DAPT for 12 months (n = 1498). Main Outcomes and Measures The primary end point was major adverse cardiac and cerebrovascular events (a composite of all-cause death, myocardial infarction, or stroke) at 12 months after the index procedure. Secondary end points included the components of the primary end point and bleeding defined as Bleeding Academic Research Consortium type 2 to 5. The noninferiority margin was 1.8%. Results Among 2993 patients who were randomized (mean age, 64 years; 795 women [26.6%]), 2912 (97.3%) completed the trial. Adherence to the study protocol was 79.3% of the P2Y12 inhibitor monotherapy group and 95.2% of the DAPT group. At 12 months, major adverse cardiac and cerebrovascular events occurred in 42 patients in the P2Y12 inhibitor monotherapy group and in 36 patients in the DAPT group (2.9% vs 2.5%; difference, 0.4% [1-sided 95% CI, –∞% to 1.3%];P = .007 for noninferiority). There were no significant differences in all-cause death (21 [1.4%] vs 18 [1.2%]; hazard ratio [HR], 1.18; 95% CI, 0.63-2.21;P = .61), myocardial infarction (11 [0.8%] vs 17 [1.2%]; HR, 0.66; 95% CI, 0.31-1.40;P = .28), or stroke (11 [0.8%] vs 5 [0.3%]; HR, 2.23; 95% CI, 0.78-6.43;P = .14) between the 2 groups. The rate of bleeding was significantly lower in the P2Y12 inhibitor monotherapy group than in the DAPT group (2.0% vs 3.4%; HR, 0.58; 95% CI, 0.36-0.92;P = .02). Conclusions and Relevance Among patients undergoing percutaneous coronary intervention, P2Y12 inhibitor monotherapy after 3 months of DAPT compared with prolonged DAPT resulted in noninferior rates of major adverse cardiac and cerebrovascular events. Because of limitations in the study population and adherence, further research is needed in other populations. Trial Registration ClinicalTrials.gov Identifier:NCT02079194

Background The second-generation drug-eluting stents (DES) have shown superiority in many studies relating to safety and efficacy when compared with the first-generation DES. However, it is unclear whether there are differences in efficacy and safety among the second-generation DES after long-term follow-up. Methods This multicenter, prospective, randomized, open-labeled trial will directly compare the efficacy and safety among the patients treated with either everolimus-eluting stent (EES), zotarolimus-eluting stent with biolinx polymer (ZES-R), or biolimus-eluting stent (BES) with minimal exclusion criteria. The primary end point is a patient-oriented composite consisted of cardiac death, myocardial infarction not clearly attributable to a nontarget vessel and clinically indicated target lesion revascularization at 24-month clinical follow-up post-index procedure. With the hypothesis that “BES is non-inferior to EES” or “BES is non-inferior to ZES-R” in primary end point, approximately 2,600 patients will be assigned to one of the types of stents using a web-based randomization system. Conclusions The CHOICE trial will directly compare the efficacy and safety of EES, ZES-R, and BES in everyday clinical practice for long-term follow-up.

Inter-arm systolic blood pressure (BP) differences (sIADs) have recently been recognized as a risk factor for cardiovascular mortality. However, sIAD reproducibility remains unresolved from a controlled trial perspective. We evaluated the between-visit reproducibility of sIADs in hypertensive patients. We examined 1875 hypertensive participants aged 20 years and older (mean age: 62.3 years, 45.4% female) from nine primary clinics and 27 secondary and tertiary hospitals. The BPs in both arms were automatically and simultaneously measured in triplicate with a cuff-oscillometric BP device. BP measurements were obtained at baseline and at 3-month follow-up time points. Increased sIAD was defined as an absolute difference of ⩾10 mm Hg in the average systolic BPs between the left and right arms. The overall mean sIAD was 4.33±4.17 mm Hg. The prevalences of increased sIAD at baseline and at the 3-month measurements were 7.6% and 7.1%, respectively. The intraclass correlation coefficient for the between-visit sIADs was 0.304 (95% confidence interval (CI) 0.262-0.344). The κ-value between the baseline and follow-up increased sIADs was 0.165 (95% CI 0.096-0.234). The percentage of patients who exhibited an increased sIAD at 3 months compared with the initially increased sIAD at baseline was 21.8%. The reproducibility of sIAD determination between baseline and the 3-month follow-up measurements lacked agreement in the hypertensive patients. Further studies should identify the relevant variables and characteristics of this poor reproducibility (CRIS number; KCT0001235).

Peripheral artery disease (PAD) is a common circulatory disorder in which narrowed arteries limit blood flow to the lower extremity and affect millions of people worldwide. Therapeutic angiogenesis has emerged as a promising strategy to treat PAD patients because surgical intervention has been showing limited success. Leg muscles of PAD patients have significantly high level of ROS (reactive oxygen species) and the increased production of ROS is a key mechanism of initiation and progression of PAD. We have recently developed H2O2-responsive polymer PVAX, which is designed to rapidly scavenge H2O2 and release vanillyl alcohol with antioxidant and anti-inflammatory activity. In this study, we investigated the therapeutic efficacy of PVAX nanoparticles for PAD using a cell culture model and a mouse model of hindlimb ischemia. PVAX nanoparticles significantly enhanced the expression of angiogenic inducers such as vascular endothelial growth factor (VEGF) and platelet endothelial cell adhesion molecule (PECAM)-1 in human umbilical vein endothelial cells (HUVEC). PVAX nanoparticles promoted revascularization and restoration of blood perfusion into ischemic tissues by upregulating angiogenic VEGF and PECAM-1. This work demonstrates that H2O2-responsive PVAX nanoparticles facilitate therapeutic angiogenesis and hold tremendous translational potential as therapeutic systems for ischemic diseases such as PAD.

Objectives: To compare the safety and efficacy of the new Coroflex TM Please stents with conventional Taxus TM Liberte stents in patients with coronary artery lesions. Background: The Coroflex TM Please stent is a new version of paclitaxel-eluting stent, and observational cohort studies have reported similar angiographic and clinical outcomes as with the first-generation stents. However, it has not been directly compared with the early generation paclitaxel-eluting stents in a multicenter, prospective, and randomized study. Methods: We randomly assigned 319 patients to receive Coroflex TM Please stents (159 patients; 198 lesions) or Taxus TM Liberte stents (160 patients; 232 lesions). The primary end point was angiographic in-segment late luminal loss at 9 months. Results: Most baseline clinical and angiographic characteristics were similar between these two groups. The Coroflex TM Please and Taxus TM Liberte stents showed similar in-segment late loss (0.40 6 0.53 mm vs. 0.39 6 0.52 mm, P 5 0.98) and rates of in-segment binary restenosis (22.2% vs. 18.8%, P 5 0.48) at 9 months. After clinical follow-up for 12 months, the two groups had similar rates of death (1.3% vs. 1.3%, P > 0.99), myocardial infarction (3.8% vs. 7.5%, P 5 0.22), stent thrombosis (2.5% vs. 1.9%, P 5 0.72), and target-lesion revascularization (7.5% vs. 7.5%, P 5 0.99). Conclusions: The Coroflex TM Please stent resulted in similar angiographic and clinical outcomes as the Taxus TM Liberte stent in patients with coronary artery lesions. V C 2012 Wiley Periodicals, Inc.

As few studies have reported the impact of transradial interventions (TRIs) versus transfemoral interventions (TFIs) on percutaneous coronary interventions using real-world registry data, we compared the clinical and procedural outcomes between TRIs and TFIs in the Korean Transradial Intervention Prospective Registry. Patients undergoing percutaneous coronary interventions were consecutively registered from February 2014 to July 2014 in this multicenter registry. Composite events were evaluated for all-cause deaths, nonfatal myocardial infarctions, and repeat revascularizations within 30 days. Nonlesion complications included access site complications and bleeding events. A total of 1,225 patients (232 for TFIs and 993 for TRIs) were analyzed. All-cause deaths and composite events were more frequent in the TFI group than in the TRI group. Procedure failures and nonlesion complications were also more frequent in the TFI group, whereas lesion complication rates were similar in the 2 groups. Procedure times were not different between the 2 groups, whereas fluoroscopy times were longer and contrast volumes were larger in the TFI group. However, in a propensity score-matched cohort, all-cause deaths, composite events, procedure failures, and lesion and nonlesion complications were not different between the 2 groups. In contrast, in the matched cohort, the procedure and fluoroscopy times were longer and the contrast volumes were larger in the TFI group. In conclusion, TRI was as effective and safe as TFI in terms of short-term clinical outcomes, procedure success rates, and complication rates, whereas TRI was more effective for reducing procedure times and hazardous exposure to radiation and contrast media.

Introduction: The use of radial artery is gradually increasing because transradial approach have shown less mortality and bleeding complications compared to transfermoral approach. But, there is little known about the differences according to radial access site except for fluoroscopic time and learning curve. Hypothesis: We aimed to compare the success rate, procedural factors and radiation exposure according to radial access site in patients who performed coronary angiography (CAG). Methods: The study population was derived from TRI prospective registry from 20 institutes in Korea from Feb 2013 to Sep 2013. Exclusion criteria were patients with data missing≥30%, invalid data, less than 19-year old patients, patient received interventional treatment, and patient who performed CAG via femoral approach. A total of 3496 among 5779 patients was assessed for data analysis. Success rate for CAG, crossover rate, procedural factors, fluoroscopic time and fluoroscopic dose were compared between right radial (RR) and left radial (LR) approach. Results: Mean age was 62.9±11.6 years and male was 1974 patients (56.5%). The use or EMLA cream was higher in LR group (29.2% vs. 14.0%, p Conclusions: In KOTRI analysis, success rate for CAG was higher in RR group, but radiation time and dose were lower in LR group. Most common cause of crossover was puncture failure.