Renal artery aneurysms (RAA) are encountered infrequently due to their rarity and lack of clinical symptoms. Management of RAA is presently evolving with broader indications for treatment and advances in endovascular approaches. We describe an unusual case of a ruptured giant RAA. A 54-year-old male presented with acute right flank pain and syncope. His past medical history was significant for refractory hypertension and chronic anticoagulation due to previous mitral valve replacement. Physical examination revealed pallor, sinus tachycardia, and severe right flank tenderness. Significant laboratory values included hematocrit 25.6 per cent (normal, 38-51%), international normalized ratio 4.3 (prosthetic valve therapeutic range 2.5-3.5), and creatinine 2.5 mg/dL (normal, 0.7-1.5 mg/dL).
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