PSA, although rare, is clinically significant due to its potential to cause lower limb ischemia, aneurysmal complications, and an increased risk of amputation in 8–10% of patients, even in advanced age. CTA of the lower limbs is essential for the rapid identification of PSA and accurate treatment planning. CTA can provide information on the anatomy of the PSA and SFA, a comprehensive evaluation of distal peripheral arteries, and has high diagnostic accuracy (an overall sensitivity of 95-97% and specificity of 91-98%) in evaluating hemodynamically significant stenoses. CTA can also determine the presence, size, and location of a PSA aneurysm, the amount of intramural thrombus, and potential signs of distal embolization or previous rupture. Finally, CTA is an optimal panoramic imaging modality for pre-treatment (surgical, endovascular, or hybrid) planning and post-treatment assessment. Magnetic resonance angiography (MRA) could be used in cases of severe iodinated contrast allergy or chronic renal insufficiency while maintaining comparable diagnostic accuracy. Treatment was traditionally reserved for symptomatic cases of PSA, while continued surveillance, usually with DUS, was recommended for asymptomatic cases. PSA management is determined by several factors, primarily the anatomical variations of the PSA, the vascular anatomy of the iliofemoral system, the severity of symptoms, the presence of aneurysmal changes, and their characteristics.Treatment strategies should be based on clinical and anatomical factors and selected after a meticulous analysis of the potential risks and benefits of the various available techniques. Different approaches (medical, endovascular, surgical, and hybrid) should be discussed and evaluated based on accurate imaging modalities (CTA or MRA), clinical symptoms, and the patient's condition.