Case 1A 79-year-old female presented with with right flank and gluteal pain radiating down the right leg, with palpable and symmetric femoral pulses and normal distal bilateral perfusion. A CTA examination (Figure 2) revealed a complete right PSA with aneurysmal degeneration measuring 57mm, along with a normal SFA (type 1). The left leg showed a fully occluded PSA with hypoplastic SFA (type 2A). The popliteal artery was supplied by collateral pathways arising from the hypoplastic SFA and the deep femoral artery. Since the patient did not experience claudication in the left lower limb, the case was discussed collegially and considered suitable for endovascular embolization of the right aneurysmal PSA, using a “sandwich technique” with vascular plugs to prevent retrograde recanalization. At clinical follow-up, complete symptom resolution was confirmed, and a one-month follow-up CTA showed complete exclusion of the PSA aneurysm.

Case 2A 53-year-old male with critical ischemia and resting pain in the right lower limb, with absent popliteal and pedal pulses on the right, and mild hypothermia of the right foot. The CTA examination (Figure 3) revealed a complete right aneurysmal PSA (23 mm at maximal caliber) with significant luminal thrombus originating from the internal iliac artery. The right external iliac artery was hypoplastic, likely due to a steal syndrome caused by the PSA. The ipsilateral SFA appeared incomplete and significantly reduced in caliber (type 2a). Thrombotic occlusion of the left popliteal artery and the tibial axis of the left tibio-peroneal trunk was observed, with filling defects in the anterior tibial artery. The posterior tibial and peroneal arteries were patent. The case was managed with a hybrid approach: a right femoro-tibial bypass with the anterior tibial artery as the target artery was performed under general anesthesia using the ipsilateral great saphenous vein in an inverted fashion, followed by endovascular embolization of the aneurysmal PSA, utilizing a 12 mm Ampaltzer Vascular Plug II deployed immediately distal to the origin of the internal pudendal artery. A 3-month follow-up CTA showed that the bypass remained patent and the aneurysm was completely excluded.

Case 3An 81-year-old female with moderate, recurrent back pain, antalgic gait, normal vital signs, and regular lower limb perfusion, sensation, and motor function. A decreased right femoral pulse was noted, combined with a regularly palpable popliteal pulse (referred to as Cowie's sign). The CTA examination (Figure 4) revealed the incidental finding of a complete right PSA originating from the internal iliac artery, with an incomplete ipsilateral SFA (type 2a). In this case, the PSA had developed as an ectatic arterial continuation (13 mm) of the internal iliac axis passing through the greater sciatic notch, penetrating the gluteus maximus muscle fibers, and following the proximal course of the sciatic nerve. Distally, the PSA followed a regular course as the popliteal-tibial axis with the anterior tibial artery originating high. The SFA was proximally short but diminutive and interrupted at Hunter's Canal. Due to the absence of aneurysmal degeneration and ischemic symptoms, the case was managed conservatively with a single antiplatelet agent, time-limited analgesics, and instructions to avoid prolonged sitting positions.

Case 4A 61-year-old female with bilateral type IIb claudication of the lower limbs, with a recent worsening on the left side. Right peripheral pulses were present, while on the left, the femoral pulse was diminished, and distal pulses were not palpable. Lower limb arterial DUS revealed a complete occlusion of the left SFA at Hunter's Canal with restoration of blood flow at the popliteal artery joint segment, where monophasic low-peak systolic flow was detected. After a multidisciplinary discussion of the clinical case, primary angiographic revascularization of the left SFA was indicated, with the aim of reducing contrast medium load due to moderate-to-severe renal impairment in the patient. Preliminary digital subtraction angiography (DSA) showed a hypoplastic and interrupted left SFA, lacking its usual continuation. The popliteal artery was supplied instead by collateral pathways from small distal branches of the SFA and deep femoral axis. Surprisingly, a vessel indicative of an incomplete PSA was perfused retrogradely through deep femoral collateral pathways and visualized both proximally and distally as short segments. Due to the incidental discovery of the PSA, the case was rediscussed, and a CTA was indicated accordingly. After the CTA examination (Figure 5), bilateral PSAs were identified. On the left, a type 2A PSA with a focal proximal occlusion and rehabilitation via gluteal collateral pathways, as well as significant distal femoral stenosis, were detected. The right lower limb presented a complete type 1 PSA. The patient was then submited on a medical management program, with slight initial improvement in symptoms. Since the PSA had assumed a dominant role as the main blood supplier to the left lower limb, the patient qualifies as a candidate for endovascular recanalization with PSA angioplasty if symptoms worsen or persist.