Tetralogy of Fallot with pulmonary atresia (TOF-PA) represents one of the most complex conotruncal anomalies encountered in fetal cardiology. Prenatal assessment is focused not only on establishing the diagnosis of pulmonary atresia and ventricular septal defect, but also on delineating the source of pulmonary blood supply, including ductus-dependent circulation and major aortopulmonary collateral arteries (MAPCAs). Accurate fetal echocardiographic characterisation has important implications for prenatal counselling, delivery planning, and postnatal management. This pictorial review summarises the prenatal imaging features of TOF-PA with MAPCAs, emphasising the role of greyscale imaging, colour Doppler, pulsed Doppler, and advanced fetal echocardiographic techniques in the evaluation of pulmonary blood supply.