Arterial autografts were introduced nearly a quarter century ago at the University of California, San Francisco and have proven their value for replacement in many demanding arterial problems. Renal artery fibrodysplasia is one of the more common lesions treated with arterial autograft. Arterial autografts that ideally match the renal artery and its branches are procured from the patient's own internal iliac artery. Either straight or branched configuration are available depending on the replacement requirements. In-situ aortorenal autografts are employed for lesions of the main renal artery or primary branches. Ex vivo repair involves temporary nephrectomy, pulsatile hypothermic perfusion and precise micro-vascular repair with unrestricted exposure, illumination, and an unhurried pace with no threat of renal ischemic insult. Autografts are attached proximally to the side of the aorta and distally to the disease-free end of the renal artery or a branch. The technique of arterial substitution for ex vivo repairs are identical except for the additional reanastomosis or reattachment of the renal vein. The arterial autograft exhibits the compliance characteristics which resemble a normal artery, maturation when used in the growing child, and durability essential for the long life span of this treated population. When the objective of a renal artery reconstruction is a normal renal arterial system, then the internal iliac artery autograft is the only choice.