Same Branches, Different Trees: A Bifurcation Connectedness Metric for Coronary Artery Segmentation and FFR-CT Decision Agreement

Fractional flow reserve derived from CT angiography (FFR-CT) simulates flow through a patient-specific vessel model, so its accuracy depends on the connectedness of the segmented tree, not only on volumetric overlap: a segmentation can reach high Dice yet sever a bifurcation, dropping the downstream subtree and reversing the treatment decision. Topology-aware losses such as clDice and Skeleton Recall act on the global centreline and can miss localised breaks. We study the Bifurcation Connectedness Score (BCS), which scores connectedness at each ground-truth bifurcation, and soft-BCS, its differentiable training surrogate. BCS captures a property of segmentation quality the standard metrics miss: it responds strongly to breaks in connectedness while staying largely unchanged under connectedness-preserving narrowing. Higher BCS accompanies closer agreement between the FFR-CT decisions a solver makes on predicted versus ground-truth geometry, most clearly in severe disease (OR 2.16, CI [1.23, 4.18]). Both decisions come from the same solver, so this reflects geometric, not clinical, fidelity. In training, soft-BCS and Skeleton Recall recover the same branches but build different trees. Recovering branches and keeping them connected are separable properties, so we recommend reporting a measure of each.

Widest-Path Reachability Fields for Connectivity-Preserving Slender Structure Segmentation

Segmenting slender curvilinear structures such as retinal vessels, cracks, and roads demands topological correctness, as even a single-pixel discontinuity can fragment a continuous network and invalidate downstream analysis. Under standard binary-mask supervision, models optimized for pixel-level overlap frequently produce topologically broken predictions. We trace this to a fundamental mismatch: pixel-wise losses distribute gradients uniformly, yet connectivity hinges on a sparse set of bottleneck pixels. These pixels are vastly outnumbered by thick structures and background, rendering their aggregate gradient contribution negligible. We term this phenomenon topological gradient starvation (TGS). To address it, we propose Widest-Path Reachability Fields (WPRF), a differentiable Max-Min reachability objective that redirects gradient flow to connectivity bottlenecks. The module is plug-and-play, backbone-agnostic, and incurs no inference overhead. WPRF implements a differentiable Max-Min objective via dynamic programming on a domain-restricted graph, coupled with a bottleneck-aware observation term that balances gradient contributions across varying structures. Compared to prior topology-aware losses that rely on post-hoc skeletonization or homology computation, WPRF directly optimizes end-to-end reachability via differentiable Max-Min algebra, enabling gradient flow to concentrate on connectivity bottlenecks without auxiliary structures. We introduce OMVIS, a new oral microvessel segmentation dataset. Experiments across nine architectures and six datasets validate the bottleneck-focused gradient routing mechanism. WPRF improves 87\% of experiments with fixed hyperparameters and achieves clDice gains of 7.2 percentage points on structurally fragile datasets.