HR-UMamba++: A High-Resolution Multi-Directional Mamba Framework for Coronary Artery Segmentation in X-Ray Coronary Angiography

Coronary artery disease (CAD) remains a leading cause of mortality worldwide, and accurate coronary artery segmentation in X-ray coronary angiography (XCA) is challenged by low contrast, structural ambiguity, and anisotropic vessel trajectories, which hinder quantitative coronary angiography. We propose HR-UMamba++, a U-Mamba-based framework centered on a rotation-aligned multi-directional state-space scan for modeling long-range vessel continuity across multiple orientations. To preserve thin distal branches, the framework is equipped with (i) a persistent high-resolution bypass that injects undownsampled structural details and (ii) a UNet++-style dense decoder topology for cross-scale topological fusion. On an in-house dataset of 739 XCA images from 374 patients, HR-UMamba++ is evaluated using eight segmentation metrics, fractal-geometry descriptors, and multi-view expert scoring. Compared with U-Net, Attention U-Net, HRNet, U-Mamba, DeepLabv3+, and YOLO11-seg, HR-UMamba++ achieves the best performance (Dice 0.8706, IoU 0.7794, HD95 16.99), yielding a relative Dice improvement of 6.0% over U-Mamba and reducing the deviation in fractal dimension by up to 57% relative to U-Net. Expert evaluation across eight angiographic views yields a mean score of 4.24 ± 0.49/5 with high inter-rater agreement. These results indicate that HR-UMamba++ produces anatomically faithful coronary trees and clinically useful segmentations that can serve as robust structural priors for downstream quantitative coronary analysis.