To examine the treatment methods and early results of renovascular repair in our contemporary patient population, we reviewed our surgical experience during a recent 54-month period. From January 1987 to July 1991, 200 patients ranging in age from 5 to 80 years (mean, 56 years) were operated on for correction of nonatherosclerotic (43 patients) and atherosclerotic (157 patients) renovascular disease. The group included 92 men and 108 women, with blood pressures ranging from 300/198 mm Hg to 120/70 mm Hg (mean, 205/113 mm Hg). Defined by preoperative serum creatinine, 129 patients (65%) had evidence of renal insufficiency (Cr greater than or equal to 1.3 mg/dl), whereas 71 patients (36%) had severe renal insufficiency (Cr greater than 2.0 mg/dl; 11 patients were dependent on dialysis). One hundred forty-seven patients with atherosclerotic renovascular disease (94%) demonstrated organ-specific atherosclerotic damage. Operative management of 291 kidneys included unilateral renal artery repair in 117 patients (58%), bilateral repair in 78 patients (39%), and primary nephrectomy in five patients (2.5%). Simultaneous aortic reconstruction was required in 64 patients (32%). There were five operative deaths (2.5% mortality rate) and four occluded renovascular repairs (1.4% primary failure) within 30 days of surgery. Hypertension was considered cured in 21% and improved in 70% of 195 operative survivors. In 70 patients with severe renal insufficiency before operation, estimated glomerular filtration rate was improved in 49% (8 of 11 patients removed from dialysis), unchanged in 36%, and worsened in 15%. Renal function response was significantly influenced by the site of disease and the operation. Twenty-six additional postoperative deaths occurred during follow-up (range, 6 to 58 months; mean, 24.4 months). Extreme atherosclerotic-renovascular disease, preoperative renal insufficiency, failure to improve renal function, and progression to dependence on dialysis after operation were associated with follow-up deaths. Although most patients had a beneficial outcome, failure to improve extreme renal insufficiency was associated with a rapid rate of death during a relatively short follow-up period.