Derivation of optimal filters for the detection of coronary arteries.

In this paper optimal filters for the detection of coronary arteries with a diameter range of 0.5-6.0 mm in digital X-ray images are derived using a computational approach. This approach is based on the two requirements for optimal detection. First, the filter should maximize the number of detected true edges and minimize the number of detected false edges. Second, if an edge has been detected, its position should be as close as possible to the true edge position in the image. Since the grey value profile in a digital X-ray image associated with an arterial vessel is asymmetric, the theory on edge detection derived by Canny has been expanded with two additional boundary constraints to make it suitable for the derivation of filters for asymmetric edges. It is demonstrated that it is possible to derive optimal filters for coronary segments. The localization error, defined by the square root of the sum of the squared systematic and random errors in the assessment of the arterial diameter, depends on the size of the coronary artery and the amount of noise in the image. In this paper, an evaluation study is described to assess the relationship between localization error and the amount of noise upon the vessel profile. For that purpose, an analytical description of the vessel profile in an angiographic image was derived. For the larger arteries the relation between noise and localization error was found to be linear and no systematic over- or underestimations were observed, even if the noise level was very high. However, it can be shown that the smallest diameter that can be measured depends on the amount of noise present in the data. Even for images that contain only a low amount of noise, arterial diameters below 0.7 mm cannot be measured accurately. If the noise in the image increases, the lowest measurable arterial diameter value also increases. Also the random error increases rapidly for vessel diameters below 1.2 mm, but with a limited amount of noise and a diameter value above 0.7 mm the random error is still acceptable [0.15 mm (21%) for 0.7-mm vessels, 0.06 mm (6%) for 1-mm vessels].

Quantitative coronary arteriography: current status and future.

Quantitative coronary arteriography (QCA) has been accepted as a means for the objective assessment of vessel sizing. Gradient field transform (GFT) is now available as a third generation QCA approach for the quantification of complex morphology. In the meantime the DICOM-3 (DICOM: Digital Imaging and Communications in Medicine) standard has been accepted for the exchange of digital data acquired in a catheterization laboratory. Issues to be resolved in digital imaging include the basic question of whether the commonly used matrix size of 512 x 512 pixels and 8 bits of density resolution is really sufficient to appreciate the same fine details as are visible on cinefilm. Other major issues of differences between the conventional cinefilm and the modern digital approach are edge enhancement and image compression. We believe that digital imaging and the DICOM-3 standard are here to stay; although the transition period may take longer and be hampered in practice by more hurdles than were originally anticipated, in a few years' time, 35-mm film will be an exception.

A model for the modulation transfer function of cardiovascular x-ray systems.

RATIONALE AND OBJECTIVES: To derive a theoretical model for the modulation transfer function (MTF) of the complete imaging chain of a cardiovascular x-ray system. A sufficiently accurate MTF model may be used in quantitative coronary arteriographic applications to decrease the systematic overestimation of small coronary vessels. The model could be used to restore blurred images in image restoration applications and also may be used for image quality assurance measurements. METHODS: Digital images of a step wedge phantom were acquired at different modes (5-, 7-, and 9-inch) of the image intensifier and at different kilovolt levels of the x-ray generator. From these images the MTFs that were used to estimate the parameters of the model were assessed. RESULTS: The total MTF of the cardiovascular x-ray imaging chain consisting of image intensifier, video camera, optical elements, and analog/digital converter can be modeled by the simple formula MTF = e-(w/f)R, where w is the frequency in linepairs per millimeter. The constants frequency f and the device index n are parameters that can be derived for an individual x-ray system using the phantom. In this formula, the contribution from the focus of the x-ray source has been excluded. The mean square error (MSE) between the measured values and those assessed from the theoretical model of the MTF for the horizontal direction was found to be equal to 0.00003 for the 5-inch mode of image intensifier, and for the vertical resolution at the 9-inch mode this MSE was equal to 0.00038. In addition, we have demonstrated that the contributions of the video camera and the image intensifier to the total MTF can be replaced by an imaginary electron-optical device. CONCLUSION: An accurate representation for the MTF of a cardiovascular x-ray system has been derived. This MTF model can be used in x-ray image quality assurance measurements and in quantitative image processing applications.

Inaccuracy of quantitative coronary arteriography when analyzed from S-VHS videotape.

In the transition period between 35-mm cinefilm as the medium for coronary arteriographic data and digital media such as CD-R, S-VHS videotape has been used both as an exchange and store medium, and for quantitative coronary arteriographic (QCA) studies. To determine the extent to which S-VHS video tape affects QCA measurements, an X-ray phantom study was completed. A plexiglass phantom with 12 straight circular tubes (0.51-5.00 mm in diameter) filled with contrast medium was recorded under clinical conditions using both the 5" and 7" modes of the image intensifier with the phantom tubes positioned horizontally as well as vertically in the field of view. The digitally acquired images were recorded on S-VHS tape without any image enhancement (raw data) and with default image enhancement. Video frames were then selected on a professional VCR such that individual tubes were positioned in the center of the field of view and digitized (512(2) x 8 bits) with a high-quality frame grabber onto a QCA workstation. The contours along the individual tubes were defined using previously validated automated contour detection techniques. For each tube, an average diameter (mm) and a standard deviation (mm) were calculated. Calibration was based on a cm-grid acquired at the same geometry as the phantom. Due to the poor signal-to-noise ratio and the limited bandwidth of the S-VHS video tape, the following objective observations were made: 1) large overestimations (up to 0.87 mm) occur for tube sizes below 1 mm for vertically positioned tubes; 2) random errors in measurements are much larger for vertically positioned tubes (0.36 mm, 7" II) than for horizontally positioned tubes (0.17 mm, 7" II); and 3) little differences in results between enhanced and nonenhanced images were found due to these deteriorating factors. In conclusion, S-VHS video tape is unacceptable for QCA and should be excluded from quantitative angiographic clinical trials.

The influence of image enhancement and reconstruction on quantitative coronary arteriography.

In the coming years, cinefilm will gradually be replaced by some digital medium for the archiving of angiographic images. However, not only the question which digital archiving medium will be used in the future is important, but also which images are to be stored. Options are to either archive the raw, unprocessed images, or the enhanced images as they are displayed on the viewing monitor in the catheterization laboratory. In the first case, an off-line workstation will need additional hardware to display the images with the same image quality as they were acquired; in the second case, the question remains whether quantitative analysis programs still provide reliable results. Goal of this study was to investigate the possible effects of image enhancement and reconstruction on the results from quantitative coronary arteriographic (QCA) measurements with the Philips ACA-package (Automated Coronary Analysis). Image enhancement was achieved by an unsharp masking approach; the reconstruction of the original image from the enhanced image was attempted by an iterative deconvolution approach. The evaluation study consisted of two parts; a technical evaluation on eleven phantom tubes with known dimensions, and a clinical evaluation study on 48 coronary lesions. The results of the technical evaluation demonstrate that the measurement errors increase for the smaller vessel sizes (< 1.2 mm) when QCA is applied to reconstructed images. The systematic difference on the smallest phantom tube (0.687 mm) on unprocessed images was limited to 0.050 mm, while it increased to 0.089 mm for the reconstructed images. Moreover, the random differences for the smaller vessel sizes increased for all processed images: for 0.159 mm for the unprocessed image to 0.189 mm for the enhanced and 0.204 mm for the reconstructed image (p < 0.01). For the larger vessels, in general, no significant differences could be observed between the results of the unprocessed and processed images. The results of the clinical evaluation study demonstrate that especially the obstruction diameter is overestimated when QCA is applied to reconstructed images (0.113 mm). Although the measurements on the enhanced images did not show a significant overestimation of the obstruction diameter, the intra-observer random difference was much higher (0.199 mm for the enhanced images versus 0.140 mm for the unprocessed images, p < 0.01). In more general terms, applying QCA on enhanced images increases the random difference values, while reconstructing the original image from the enhanced images increases the systematic errors in the measured diameters. This study has clearly demonstrated that especially the smaller diameter values (< 1.2 mm) are influenced by image enhancement. Therefore, to obtain quantitative results with the desired small values for systematic and random differences, requires that the raw, unprocessed image data be archived.

Comparison between regional myocardial perfusion reserve and coronary flow reserve in the canine heart.

Diameter stenosis and flow reserve are indices of morphological and functional severity of coronary artery stenosis. Flow reserve can be determined at coronary arterial or at myocardial level. In the presence of functional collateral circulation, coronary flow reserve and myocardial perfusion reserve may differ. We studied coronary flow, coronary flow reserve and myocardial perfusion reserve in an open chest dog model with intact collateral circulation, before and after induction of coronary artery stenosis. Coronary flow was determined with perivascular ultrasonic flow probes and myocardial perfusion reserve from digital angiographic images, in the stenotic as well as the adjacent non-stenotic coronary arteries. Before induction of a stenosis, a significant correlation existed between coronary flow reserve and myocardial perfusion reserve of the left anterior descending (r = 0.59; P < 0.005) and the left circumflex arteries (r = 0.84, P < 0.005). In stenotic arteries, coronary flow reserve and myocardial perfusion reserve decreased significantly (P < 0.005), but in the adjacent non-stenotic arteries coronary flow reserve was not affected. Myocardial perfusion reserve in the non-stenotic adjacent left anterior descending artery decreased significantly (P < 0.05) and no correlation was found between coronary flow reserve and myocardial perfusion reserve, whereas in the adjacent non-stenotic left circumflex artery there was no statistically significant decrease (4.1 +/- 1.6 --> 3.5 +/- 1.4) but there was a good correlation between coronary flow reserve and myocardial perfusion reserve (r = 0.85; P < 0.005). This study demonstrates that, in the presence of a stenosis and functioning collateral circulation, coronary flow reserve is not a reliable predictor of myocardial perfusion reserve; both parameters provide mutually complementary information.

Automated and accurate assessment of the distribution, magnitude, and direction of pincushion distortion in angiographic images.

RATIONALE AND OBJECTIVES: Pincushion distortion continues to be a potential problem for the accurate assessment of arterial and catheter dimensions from x-ray angiograms. The authors investigate whether the distortion of state-of-the-art intensifiers is yet small enough to be neglected, and whether the rotation/angulation of the x-ray system plays a significant role. METHODS: The location and degree of distortion from x-ray images of a centimeter grid, which is positioned against the input screen of the image intensifier, are assessed automatically using image processing techniques. A value for the maximum amount of change in the distortion vector field is derived that allows the estimation of the maximum relative error associated with a diameter measurement uncorrected for pincushion distortion. RESULTS: The accuracy of the algorithm itself was assessed by rotating and translating the centimeter grid under the image intensifier at anteroposterior position. For the distortion vector length, the standard deviation in the measurement of the distortion areas was found to be 3.7 cm2 (1.3% of the total area). For the gradient values, the standard deviation was 2.2 cm2 or 0.75% of the total image intensifier area. In the second evaluation study, the centimeter grid was fixed onto the input screen of the image intensifier, and the gantry was rotated to span all possible positions of the system. In this case, the changes in measured areas were often much larger (up to 51.25 cm2 for a 9-inch image intensifier, equivalent to 15.6% of the total image intensifier area) than the standard deviations that had been found in the first evaluation study. CONCLUSIONS: The distortion is highly dependent upon the actual spatial position of the image intensifier, and correcting for pincushion distortion may therefore introduce larger errors than leaving the measurements uncorrected.

A new approach for the quantification of complex lesion morphology: the gradient field transform; basic principles and validation results.

OBJECTIVES: This report describes the basic principles and the results from clinical evaluation studies of a new algorithm that has been designed specifically for the quantification of complex coronary lesions. BACKGROUND: Currently used edge detection algorithms in quantitative coronary arteriography, such as the minimum cost algorithm, are limited in the precise quantification of complex coronary lesions characterized by abruptly changing shapes of the obstruction. METHODS: The new algorithm, the gradient field transform, is not limited in its search directions and incorporates the directional information of the arterial boundaries. To evaluate its accuracy and precision, 11 tubular phantoms (sizes 0.6 to 5.0 mm), were analyzed. Second, angiographic images of 12 copper phantoms with U-shaped obstructions were analyzed by both the gradient field transform and the minimum cost algorithm. Third, 25 coronary artery segments with irregularly shaped obstructions were selected from 19 routinely acquired angiograms. RESULTS: The plexiglass phantom study demonstrated an accuracy and precision of -0.004 and 0.114 mm, respectively. The U-shaped copper phantoms showed that the gradient field transform performed very well for short, severe obstructions, whereas the minimum cost algorithm severely overestimated the minimal lumen diameter. From the coronary angiograms, the intraobserver variability in the minimal lumen diameter was found to be 0.14 mm for the gradient field transform and 0.20 mm for the minimum cost algorithm. CONCLUSIONS: The new gradient field transform eliminates the limitations of the currently used edge detection algorithms in quantitative coronary arteriography and is therefore particularly suitable for the quantification of complex coronary artery lesions.

Accuracy and precision of quantitative digital coronary arteriography: observer-, short-, and medium-term variabilities.

Coronary arteriograms are increasingly acquired and stored in digital format, which allows instantaneous review of the pictorial data during the cardiac catheterization procedure. To support the angiographer in choosing the optimal sizes of the recanalization devices and studying the efficacy of the recanalization procedures, we have developed a new analytical software package (Automated Coronary Analysis = ACA) on the Philips DCI (-SX) digital cardiac imaging system. The ACA-package allows the objective and reproducible assessment of the morphologic and functional severity of coronary obstructions. Required user interaction is limited to the definition of the start and end points of the coronary segment to be analyzed. Automated contour detection is based on the use of first and second derivative functions along scanlines perpendicular to the automatically computed vessel pathline in the first iteration and perpendicular to the initial contours in the second iteration. These derivative functions have been modified based on the line spread function of the X-ray imaging chain, which is of particular importance for the accurate measurement of small vessel sizes. Phantom studies have indeed demonstrated that vessel sizes down to 0.66 mm can be measured accurately and reproducibly. Inter- and intraobserver variability studies have demonstrated a variability in the obstruction diameter of 0.11 mm and 0.10 mm, respectively, and in the percent diameter stenosis of 5.64% and 3.18%, respectively. These variability studies have been extended to short-term studies with repeated acquisition in the same angiographic views after 5 min and to medium-term studies with repeated acquisition in the initial angiographic views at the end of the catheterization procedures. With these standardized repeated acquisition and analysis procedures, the variabilities in the obstruction diameters increased to 0.19 and 0.18 mm, respectively, and remained below 6% in the percent diameter stenosis (5.61% and 5.28%, respectively). With an analysis time of approximately 15 sec on the DCI-SX, an efficient tool is now available in the catheterization laboratory for the objective and reproducible assessment of vessel dimensions and changes therein as a result of recanalization procedures.

Angiographic assessment of dimensions of 6F and 7F Mallinckrodt Softouch coronary contrast catheters from digital and cine arteriograms.

Coronary contrast catheters are almost exclusively used for calibration purposes in quantitative coronary arteriography. In this study we have assessed the suitability of new 6F and 7F Mallinckrodt nylon catheter with Softouch tip with improved imaging specifications for such calibration purposes both from digital and cinefilm images using new analytical QCA-software packages (Philips DCI/ACA and Medis CMS). The average signed differences between the angiographically measured dimensions at 100% contrast fillings and acquired at 3 different kV-levels (60, 75 and 90 kV) were -3.3% and 0.6% for the 6F and 7F catheter tips, respectively as measured with the ACA-package on digital images, and -0.4% and 2.1%, respectively, as measured with the CMS-system on cinefilm images. The pooled standard deviations were 0.102 mm and 0.107 mm for the 6F and 7F catheter tips, respectively, as measured with the ACA-package, and 0.080 mm and 0.083 mm, as measured with the CMS-system. The deviations for the nylon shafts were much larger. It became also clear that neither the filling of the catheters, nor the kV-level used, had any appreciable effect on the measurement accuracy for the Softouch tips, which facilitates the frame selection in QCA-studies. From these data it can be concluded that the nontapering parts of the 6F and 7F Mallinckrodt Softouch tips are very well suitable for QCA calibration purposes, but that the nylon shafts are not.

A new approach for the automated definition of path lines in digitized coronary angiograms.

For the quantitative analysis of a coronary segment from a coronary (cine)angiogram, an initial path line is required which functions as a model for the subsequent automated contour detection. For on-line applications, a new method for the automated definition of arterial path lines has been developed. Required user-interaction consists of the manual definition of a beginning and an endpoint of the arterial segment to be analyzed. The method is based on a combination of a beam tracer and a box technique. A validation study was performed on 47 non obstructed arteries of various lengths and diameters, and on 56 arterial segments with obstructions (up to 86 percent diameter stenosis). In 89% of the cases an acceptable path line was found after the first iteration; the success score increased to 99%, if a simple manual correction was allowed (2 iterations). The method is extremely fast: the overall average search time for the first iteration was 266 ms, for the second iteration 211 ms. Therefore, it may be concluded that this new technique for the automated definition of arterial path lines is extremely suitable for on-line applications.