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.