OBJECTIVE: To assess the incidence of coronary artery ectasia (CAE) and its associated clinical characteristics and outcomes over a long follow-up period in Saudi Arabia. METHODS: We retrospectively analyzed all coronary angiography procedures performed between January 2013 and June 2023. Patients with CAE were included in the final analysis. RESULTS: During the 10-year period, 10,397 patients underwent coronary angiography. The CAE was diagnosed in 242 patients, yielding an incidence of 2.3%. The majority were male (92.6%). The average age was 57.15 ± 11.76 years. The right coronary artery (RCA) was the most involved vessel (65.2% of all patients). The most common anatomical morphology of ectasia was diffuse (92.5%), followed by saccular (4.5%) and fusiform (3%). A total of 26.8% of the patients had isolated CAE, while 73.1% had mixed CAE and atherosclerotic cardiovascular disease (ASCVD). The rates of diabetes (27.7% vs. 55.4%, p < 0.0001) and smoking (32.3% vs. 49.2%, p < 0.011) were significantly greater in the mixed CAE and ASCVD group. During a median follow-up of 510 days, the prevalence of composite endpoint was significantly greater in the mixed CAE and ASCVD group than in the isolated CAE group (29% vs. 14%, p = 0.04). CONCLUSION: Coronary artery ectasia is an uncommon angiographic finding, most often occurring in association with obstructive CAD. Outcomes appear to differ according to the presence of coexisting obstructive disease, with fewer events observed among patients with isolated CAE.