A 62-year-old man presented with acute abdominal and flank pain, oligoanuria and severe acute kidney injury. Unenhanced CT imaging did not detect urolithiasis or hydronephrosis. There was an early blood pressure surge followed by an intense inflammatory response, with a rise in peripheral blood leucocytes and C reactive protein. His urinalysis was bland but the serum lactate dehydrogenase was markedly elevated. CT angiograms demonstrated multiple pulmonary emboli and bilateral renal artery thromboembolism, with occlusion of the left main renal artery. Despite an 88-hour delay from pain onset, catheter-directed thrombolysis and thromboaspiration of both renal arteries were successfully performed, allowing the patient to recover enough kidney function to cease haemodialysis. A patent foramen ovale with right-to-left shunting was discovered, and paradoxical embolism was suspected as the cause of renal infarction. The benefit of catheter-directed reperfusion after prolonged bilateral renal ischaemia is not easily predicted by the severity or duration of acute kidney injury alone.