Congenital coronary artery malformations can take several forms: (1) anomalous left or right coronary artery arising from the pulmonary artery, (2) anomalous aortic origin of the coronary arteries, (3) single coronary artery with or without anomalous course between the aorta and pulmonary artery, congenital atresia or stenosis of the left main coronary artery, (4) coronary artery fistulas, and (5) coronary artery bridging. Acquired coronary lesions include: (1) coronary artery aneurysms and stenoses associated with Kawasaki Disease, (2) iatrogenic injuries caused by transcutaneous invasive procedures or surgical complications, and (3) rare instances of sharp or blunt trauma. This chapter will highlight the necessary extant reparative procedures to repair congenital and acquired coronary artery lesions and show how complications can occur. New illustrations will show actual drawings of surgical complications that will require successful resolution.