Anatomical Variations of Coronary Arteries and Their Clinical Implications: A Systematic Review

Abstract

Coronary artery anatomical variations range from benign incidental findings to potentially life-threatening anomalies. The increasing use of coronary computed tomography angiography (CCTA) has improved their detection, anatomical characterization, and clinical assessment. Objectives: To systematically identify major coronary artery anatomical variations and evaluate their clinical implications, particularly in distinguishing benign variants from high-risk anomalies. Methods: This systematic review followed the PRISMA 2020 guidelines. The PubMed, Web of Science, and Scopus databases were searched from January 2020 to December 2025. Studies reporting coronary artery anatomical variations in humans were included if they were primary studies reporting clinical implications. Reviews, systematic reviews, meta-analyses, case reports, case series, pilot studies, and non-human studies were excluded. The studies were screened and data extracted by two reviewers independently. Results: Eleven studies were included. Right coronary dominance was the most common dominance pattern. Myocardial bridging was the most frequently reported course variation, whereas coronary artery fistulae were uncommon. Interarterial and intramural courses were associated with the greatest clinical risk, including myocardial ischemia, syncope, arrhythmias, and sudden cardiac death. Most other variations were benign but remained important during catheterization and cardiac surgery. Conclusions: Most coronary artery variations are benign, whereas clinically significant anomalies are uncommon. Their prognostic importance depends primarily on the anatomical origin and proximal course. CCTA supports accurate characterization, risk stratification, and individualized clinical management.