In this paper, a combined Fractal and Wavelet (CFW) compression algorithm targeting x-ray angiogram images is proposed. Initially, the image is decomposed using wavelet transform. The smoothness of the low frequency part of the image appears as an approximation image with higher self similarities, therefore, it is coded using a fractal coding technique. However, the rest of the image is coded using an adaptive wavelet thresholding technique. This model is implemented and its performance is compared with best performances of the available published algorithms. A data set containing 1000 x-ray angiograms is used to study the performance of the algorithm. A minimum compression ratio of 30 with a peak signal to noise ratio (PSNR) of 36 dB and percent diameter stenosis deviation of (<0.2%) was achieved. Results demonstrate the effectiveness of the proposed technique in obtaining a diagnostic quality of reconstructed images at very low bit rates.