Congenital coronary artery anomalies and anatomical variants: a comprehensive radiological review with emphasis on coronary CT angiography

Congenital coronary artery anomalies and anatomical variants encompass a wide spectrum of configurations, ranging from benign incidental findings to abnormalities associated with myocardial ischemia, malignant arrhythmias, and sudden cardiac death. This review provides a comprehensive radiological overview of normal coronary anatomy, common anatomical variants, and clinically significant congenital coronary anomalies, with particular emphasis on risk stratification and imaging assessment. A structured narrative review of the current literature was performed, focusing on coronary artery anatomy, classification systems, and imaging findings relevant to congenital anomalies. The role of coronary computed tomography angiography (CCTA) is highlighted, with comparison to invasive coronary angiography and cardiac magnetic resonance imaging, emphasizing their complementary diagnostic value. While most anatomical variants are clinically silent, a subset of congenital anomalies carries important prognostic implications, especially in young individuals and competitive athletes without structural heart disease. CCTA enables high-resolution, three-dimensional evaluation of coronary origin, course, and spatial relationships with adjacent cardiovascular structures, allowing reliable identification of high-risk features such as inter-arterial and intramural courses, acute take-off angles, and slit-like ostia. Standardized classification systems proposed by major cardiovascular imaging societies facilitate uniform reporting and risk assessment. Overall, CCTA plays a pivotal role in detection, anatomical characterization, and risk stratification of congenital coronary anomalies, differentiating benign variants from potentially malignant patterns. Integration with functional imaging modalities and emerging artificial intelligence applications may further enhance diagnostic accuracy and support optimal clinical management in the future.