Seventy consecutive operations involving the renal arteries were reviewed to identify factors linked to perioperative mortality. Aortorenal bypass (n = 29), endarterectomy (n = 12), extraanatomic bypass (n = 12), thrombectomy (n = 4), and reimplantation (n = 13) were associated with a 16% perioperative mortality that was often secondary to multisystem organ failure. Patients who died exhibited a higher serum creatinine (3.4 vs 2.1 mg/dL; P < 0.05). Stratification of patients by risk revealed higher American Society of Anesthesiologists (ASA) (P < 0.005) and modified Acute Physiology Score, and Chronic Health Evaluation (APACHE II) (P < 0.02) score among patients who died. Higher mortality was also observed after bilateral renal artery operations (31% vs 5%; P < 0.005) or concomitant mesenteric revascularization (37% vs 12%; P < 0.05), but not simultaneous aortic procedures (18% vs 11%; P = NS). Bilateral operation (P < 0.0001), age (P < 0.001), and ASA class (P < 0.01) were independent predictors of mortality according to multivariate analysis. Because of higher mortality in these specific situations, modification or limitation of operative scope may be appropriate.