PSA is a rare vascular anomaly resulting from the failure of the regression of the sciatic artery (SA), a branch of the umbilical artery providing blood supply to the lower limbs during embryonic development. Typically, the distal part of the SA regresses by the third month of gestation when the external iliac artery develops, and the superficial femoral artery (SFA) becomes responsible for the lower limb's perfusion. However, in PSA, the sciatic artery remains intact and follows the sciatic nerve to the popliteal artery, potentially associated with hypoplasia or agenesis of the iliac-femoral axis

According to anatomical characteristics, PSA is classified in five types (figure 1).

While PSA can be discovered incidentally, approximately 80% of cases present with symptoms, often due to sciatic neuralgia. The condition can also lead to the development of gluteal aneurysms in about 48% of cases due to repeated compression or defects in the arterial wall, which can result in a pulsatile mass, compressive neuropathy, sudden rupture, or ischemic manifestations from thrombotic occlusion or distal embolism. PSA may be misdiagnosed as chronic obliterative arteriopathy or Buerger’s disease, delaying treatment and increasing the risk of aneurysm rupture, distal embolism, and limb amputation.

Therefore, PSA is considered a highly morbid condition, and prompt identification using duplex ultrasound (DUS) is necessary, along with proper diagnosis and treatment planning using computed tomography angiography (CTA).

Management of PSA depends on the vascular anatomy (whether the PSA and SFA are complete or incomplete), the clinical presentation, and the presence of aneurysms. PSA cases without aneurysmal degeneration may be managed with medical treatment and active surveillance. For symptomatic cases, particularly those with complete PSA or SFA, percutaneous transluminal angioplasty (PTA) with stenting or catheter-directed thrombolysis may be appropriate. For PSAs with incomplete SFA, a femoro-popliteal bypass with proximal popliteal artery ligation may be required.

In cases of PSA with aneurysmal degeneration, endovascular approaches such as coiling or stent-graft insertion are preferred over open surgery due to the high risk of sciatic nerve damage. Surgical excision is increasingly avoided in favor of these less invasive techniques.

We present a series of four cases of PSA with different anatomical characteristics, patients’ age and clinical presentations. All cases were diagnosed in our institution and managed after multidisciplinary discussion involving vascular surgeons and interventional radiologists. Whereas selective angiography was performed only in endovascular approaches, computed tomography angiography (CTA) was in all patients the decisive diagnostic modality. Treatment strategies were selected on the basis of clinical and anatomical factors, after the evaluation of the potential risks and benefits of each technique.