Renal artery aneurysms require selective treatment, depending on size, localisation, and morphology as well as on singular or multiple locations. Spontaneous course without sequelae was reported in smaller series, however, there is an indication for treatment of aneurysms without calcification, women in childbearing age and in cases of unilateral kidney. Besides endovascular procedures there are different surgical techniques of in vivo or ex vivo repair. Treatment of aneurysms of side branches is more complicated and requires ex vivo treatment in selected cases. Ex vivo preparation of the kidney offers nearly identical surgical complications as the renal transplantation, limiting its indication. The clinical course and treatment options of a 53 year old female demonstrates that even nephrectomy might be the treatment of first choice in case of normal contralateral kidney.