Self-training for cross-centre coronary vessel segmentation in X-ray angiography using pre-contrast frame subtraction

Objective: X-ray angiography is the gold standard imaging modality for cardiovascular diseases. However, current deep learning approaches for X-ray angiogram analysis are severely constrained by the scarcity of annotated data. While large-scale self-supervised learning (SSL) has emerged as a promising solution, its potential in this domain remains largely unexplored, primarily due to the lack of effective SSL frameworks and large-scale datasets. Methods: To bridge this gap, we introduce a vascular anatomy-aware masked image modeling (VasoMIM) framework that explicitly integrates domain-specific anatomical knowledge. Specifically, VasoMIM comprises two key designs: an anatomy-guided masking strategy and an anatomical consistency loss. The former strategically masks vessel-containing patches to compel the model to learn robust vascular semantics, while the latter preserves structural consistency of vessels between the original and reconstructed images, enhancing the discriminability of the learned representations. In conjunction with VasoMIM, we curate XA-170K, the largest X-ray angiogram pre-training dataset to date. Results: We validate VasoMIM on four downstream tasks across six datasets, where it demonstrates superior transferability and achieves state-of-the-art performance compared to existing methods. Conclusion: Incorporating vascular anatomical knowledge into self-supervised pre-training enables more discriminative and transferable representations for X-ray angiogram analysis. Significance: These findings highlight the significant potential of VasoMIM as a foundation model for advancing a wide range of X-ray angiogram analysis tasks. VasoMIM and XA-170K are available on GitHub and Hugging Face, respectively.

Accurate segmentation of coronary arteries in X-ray angiography videos is essential for quantitative coronary analysis and image-guided interventions. However, accurate segmentation remains challenging because coronary vessels are thin and exhibit low contrast, while the presence of catheters, guidewires, and complex anatomical background structures can further interfere with vessel delineation. Existing U-Net- and Transformer-based models provide strong baselines, but their shared feature-adaptation pathways may be insufficient for heterogeneous angiographic appearances. In this paper, we propose a prompt-free mixture-of-experts (MoE) feature adapter for binary coronary artery segmentation. Built upon parameter-efficient Vision Transformer adapters, the proposed method uses multiple lightweight experts with input-dependent top-$k$ routing to adaptively refine vessel-related features while limiting active computational cost. Experiments on MOSXAV and external evaluation on XACV show that the proposed method outperforms representative baselines and improves cross-dataset generalisation. These results suggest that MoE-based adapter learning is effective for robust coronary artery segmentation in X-ray angiography videos.

Coronary artery disease, a leading cause of cardiovascular mortality worldwide, can be assessed non-invasively by coronary computed tomography angiography (CCTA). Although deep learning has advanced automated CCTA analysis, clinical translation remains constrained by the scarcity of expert-annotated data and by the spatial sparsity of coronary pathology, which occupies only a small fraction of each scan. Widely used label-free pretraining strategies, such as masked image modeling and contrastive learning, optimize for global anatomical reconstruction and tend to under-represent these tiny localized pathological features. Here we present CORA, an annotation-efficient model for comprehensive coronary artery disease assessment. Rather than reconstructing background anatomy, CORA learns from volumetric CCTA through a synthesis-driven self-supervised strategy: an anatomy-guided engine inserts diverse synthetic calcified and non-calcified lesions into unlabeled scans, reframing pretraining as an abnormality-detection task that biases representation learning toward clinically relevant disease features. We pretrained CORA on 10,138 unlabeled CCTA volumes and evaluated it across datasets from nine independent hospitals. Across plaque characterization, stenosis detection, and coronary artery segmentation, CORA consistently outperformed strong self-supervised pretraining baselines, with the largest gains on external multi-center data, indicating robust generalization under distributional shift. Coupling the imaging encoder with structured clinical variables further enabled near-term major adverse cardiac event (MACE) risk stratification. Our results show that pathology-centric, synthesis-driven pretraining is an effective and scalable strategy for annotation-efficient coronary artery disease assessment from CCTA.