Association Between Coronary Artery Anomalies, Obstructive Coronary Disease, and Procedural Complexity During Coronary Angiography

BACKGROUND: The clinical and procedural implications of coronary artery anomalies (CAAs) remain incompletely defined. AIMS: To evaluate the association between anomalous coronary anatomy, obstructive coronary artery disease (CAD), and procedural complexity during coronary angiography and percutaneous coronary intervention (PCI). METHODS: In this retrospective single-center study, all patients who underwent coronary angiography between 2014 and 2025 were screened. Among 9567 angiograms, 134 patients (1.4%) had CAAs of origin/course or termination (excluding myocardial bridges). A vessel-level data set was constructed, and obstructive CAD (≥ 50% stenosis) was compared between anomalous and non-anomalous arteries using clustered logistic regression. Fluoroscopy time, contrast volume, catheter selection, and selective cannulation success were evaluated using multivariable and descriptive analyses. RESULTS: Of the 134 cases, 53 were anomalies of origin (52 from the aorta and 1 from the pulmonary artery), 51 were variants of origin (28 separate LAD and LCx ostia, 21 anterior RCA take-offs, and 2 high take-offs of the left coronary artery), and 30 were anomalies of termination (27 coronary-pulmonary artery fistulas, 1 coronary-cardiac chamber fistula, and 2 coronary-venous fistulas). Obstructive CAD was more frequent in anomalous versus non-anomalous arteries (33.9% vs. 24.2%) and remained independently associated with anomalous anatomy (OR 1.61, 95% CI 1.15-2.26; p = 0.006). Catheterization of anomalies of origin was independently associated with longer fluoroscopy time (+3.72 min; p = 0.0015) and higher contrast use (+49.6 mL; p = 0.004). PCI involving anomalous arteries required longer fluoroscopy time compared with PCI of non-anomalous vessels (median 14.6 vs. 8.4 min; p = 0.033). CONCLUSIONS: Anomalous coronary arteries are associated with increased vessel-level prevalence of obstructive CAD and greater procedural complexity, particularly in anomalies of origin.