During and 8-year period, 51 patients with renovascular hypertension were evaluated. Etiologies of renovascular disease included atherosclerosis 29 (57%), Takayasu's arteritis 11(22%), fibromuscular dysplasia six (11%), renal artery dissection two (4%), trauma two(4%¿ and aneurysm one (2%). Fifteen (29%) patients had bilateral renal artery disease, and 16 (31%) had associated chronic renal failure. Seven patients initially underwent percutaneous transluminal angioplasty, three of whom later required operative intervention for recurrent hypertension, and one required repeat angioplasty. Three patients had no further intervention. Forty-seven patients underwent surgical revascularization tailored to the angiographic and intraoperative findings. Procedures performed included 36 (55%) aortorenal bypasses; 12 (18%) endarterectomies; five (8%) ex-vivo reconstructions; three (4%) renal artery reimplantations; two (3%) other visceral artery-to renal (hepatic/splenic) reconstructions; one (2%) renal artery patch graft; and seven (10%) nephrectomies. Concomitant aortic replacement occurred in 20 cases. There were two deaths, and remedial operations for recurrent hypertension were required in three patients. The mean follow up was 12 months (range 6-45 months). Hypertension was cured in 25 (57%), improved in 14(32%), and unchanged in five (11%). Of the 16 patients with chronic renal failure, eight (50%) had a reduction in serum creatinine >10%. The etiology of renovascular hypertension is variable. Although transluminal angioplasty may be indicated in selected patients, surgical revascularization is usually necessary. A flexible operative approach to accommodate the variable patterns of renal artery disease optimizes surgical results. Renal revascularization may provide and improvement in excretory renal function.