We sought to determine the anatomic characteristics of coronary arteries arising from an anomalous location (CAAL) detected on coronary computed tomography angiography (CTA) and assess the impact of high-risk anatomic characteristics on patient management and outcomes. We reviewed 9,774 consecutive CTA studies performed in adults between 2008?2013 and identified 114 with CAAL. CTA examinations were analysed to determine CAAL type, CAAL course (pre-pulmonary, interarterial, septal or retroaortic) and whether additional high-risk anatomic characteristics were present (luminal compression, intramural course, slit-like ostium and acute takeoff angle). Patients were contacted at mean 27.1-months to determine safety outcomes. The prevalence of CAAL was 1.14 (114 of 9,974), with 36 (32 ) having anomalous right coronary artery from left coronary sinus, 71 (62 ) having anomalous left coronary artery from right coronary sinus and 7 (6 ) having a coronary artery arising outside coronary sinuses. Fifty-six patients (49 ) had =1 high-risk anatomic characteristic on CTA. Ten patients (9 ) underwent surgical intervention. Patients with high-risk anatomic features more frequently underwent functional testing (46 vs. 12 , P = 0.01) and surgical intervention (14 vs. 3 ; P = 0.04) compared to patients without high-risk features. Patients undergoing surgery were more likely to have obstructive coronary disease on CTA than patients managed conservatively (50 vs. 13 , P = 0.01). There was no cardiac death or ACS at follow-up (100 complete). High-risk anatomic features on CTA in patients with CAAL more frequently lead to surgical management. Regardless of CAAL type, presence of high-risk anatomic characteristics or management strategy, the medium-term outcome of adults with CAAL is excellent.