The optimal surgical management of combined aortic and renal atherosclerosis has not been defined. A modified technique of renal endarterectomy performed through the transected aorta before anastomosis of the aortic prosthesis is presented. The surgical course and early follow-up results of the first 44 consecutive patients treated by this technique are reported. Twenty-three patients (25%) had symptomatic coronary artery disease, 36 patients (82%) had arterial hypertension, and 28 patients (64%) had elevated serum creatinine levels (mean 2.10 mg/dl). Primary indications for operation related to aortic disease in 39 patients (89%) and to poorly controlled hypertension in five patients (11%). Seventy-five renal arteries were revascularized; 11% of these arteries were occluded. Revascularizations were bilateral in 27 patients (61%), involved a solitary kidney in three patients (6%), and were unilateral in 14 patients (32%). Aortobifemoral bypass grafting was performed in 16 patients (36%), aortoiliac bypass was performed in 15 patients (34%), and infrarenal aortic replacement was performed in 11 patients (25%). Postoperative complications developed in 14 patients (32%). There were two postoperative deaths (4%). Nineteen patients had transient increases in serum creatinine levels greater than 0.5 mg/dl. Two patients required postoperative dialysis, neither related to failure of their renal revascularization. There were five late deaths, all as a result of myocardial infarction. Renal function improved in four patients and remained stable in 22 patients. Blood pressure was improved in 64% of patients previously hypertensive. These preliminary results indicate that renal endarterectomy through the transected aorta along with aortic reconstruction is a safe, efficient, and effective means of treating these complex lesions.