A Hidden Triple Threat: A Case of Concurrent Renal Artery Stenosis, Dissection, and Pseudoaneurysm

The simultaneous occurrence of renal artery stenosis, pseudoaneurysm, and dissection in a single native vessel is rare and poses a severe threat to renal survival. Herein, we present a case of a 50-year-old male patient on alternative medications for hypertension who presented with a three-day history of vomiting, dehydration, and 12 hours of anuria. Initially managed for dehydration and acute kidney injury, his persistent hypertension and worsening renal function prompted further investigation. Initial renal artery Doppler did not show acute changes; the patient's clinical status necessitated hemodialysis. A re-evaluation, prompted by undisclosed family history and a neglected history of a small left kidney since childhood, led to a repeat Doppler and subsequent CT renal angiogram. Findings revealed right renal artery stenosis, dissection, and a pseudoaneurysm. Urgent percutaneous transluminal renal angioplasty (PTRA) successfully restored perfusion, resolving the patient's renal failure and dialysis dependency. This case underscores that renal artery Doppler is highly operator-dependent and can miss critical pathologies. It highlights the necessity of maintaining a high index of suspicion for renovascular causes in hypertensive patients and emphasizes that when clinical findings are incongruent with initial imaging, further invasive diagnostic imaging is essential to ensure timely intervention.