Abstract Background Peripheral artery disease (PAD) is usually diagnosed with non-invasive arterial testing methods such as Doppler ultrasound or computed tomography angiography and treated with revascularization using contrast media, which increases the risk of contrast nephropathy and the need for subsequent renal replacement therapy, especially in patients with advanced chronic kidney disease (CKD). Therefore, it is important to identify a worthy alternative strategy for use in high-risk patients. Case summary We present the case of a 79-year-old man with bilateral claudication and advanced CKD. The patient had a high risk of sustained reduction in renal function and requirement of renal replacement therapy in the event that contrast media was used. Therefore, we planned a zero-contrast strategy for diagnosis and treatment. The case was diagnosed as bilateral stenotic iliac disease with non-contrast magnetic resonance angiography. Zero-contrast intervention was conducted successfully under magnetic resonance angiography and intra-vascular ultrasound guidance, resulting in an excellent clinical outcome and avoidance of worsening renal function. Discussion This zero-contrast strategy appears to be a viable alternative to angiography using contrast for diagnosis and treatment in patients with PAD and advanced CKD where contrast use is relatively contraindicated.