We delineate the current role of extra-anatomical revascularization techniques in the treatment of patients with atherosclerotic renal artery stenosis. There are 2 components to this study. In part 1 all abdominal aortograms performed between 1989 and 1993 were reviewed to document the presence of significant abdominal aortic and visceral arterial atherosclerosis in patients with atherosclerotic renal artery stenosis. A total of 254 patients with atherosclerotic renal artery stenosis was identified. Among 44 patients with severe unilateral disease the incidence of significant abdominal aortic atherosclerosis was 75%. The incidence of significant (greater than 50%) stenosis of the celiac, right common iliac and left common iliac arteries was 52%, 32% and 27%, respectively. In 129 patients with severe atherosclerotic renal artery stenosis bilaterally or in a solitary kidney the incidence of significant abdominal aortic atherosclerosis was 81%, and the incidence of significant (greater than 50%) stenosis of the celiac, right common iliac and left common iliac arteries was 59%, 57% and 59%, respectively. These data indicate that hepatorenal, splenorenal and iliorenal bypass cannot be performed in many patients with atherosclerotic renal artery stenosis due to significant disease involving the donor vessels for these operations. In part 2, all patients undergoing surgical renal revascularization with an extra-anatomical bypass operation between 1980 and 1992 were reviewed. A total of 175 operations was done in 171 patients, including hepatorenal bypass in 59, splenorenal bypass in 54, iliorenal bypass in 37, thoracic aortorenal bypass in 23, renal autotransplantation in 1 and superior mesentero-renal bypass in 1. There were 5 operative deaths (2.9%) and 7 cases of postoperative graft thrombosis (4%). All patients with poorly controlled hypertension were cured or improved postoperatively. Among patients with ischemic nephropathy, postoperative renal function improved in 35%, remained stable in 47% and deteriorated in 18%. Extra-anatomical techniques remain an important component of the surgical armamentarium for atherosclerotic renal artery stenosis. Thoracic aortorenal bypass is a useful new approach in patients with significant celiac and iliac occlusive disease.