This review summarizes our experience with the operative management of renovascular hypertension (RVH) in elderly patients (>_60 years of age). From 7/87 through 6/95,230 of 428 adult patients (54%) undergoing operation of renovascular hypertension at our center were in their seventh (153 patients), eighth (70 patients) or ninth (7 patients) decade of life (mean age: 68 years). There were 117 males and 113 females with blood pressures ranging from 280/190 to 178/90 (mean: 202/102 mmHg). One hundred and eighty patients (78%) had renal insufficiency (i.e., serum creatinine >_ 1.3 mg/dl). One hundred and four patients (45%) had severe insufficiency (i.e., serum creatinine >_2.0 mg/dl), with 23 of these patients being dialysis dependent prior to operation. Two hundred and eighteen (95%) had evidence of organ specific atherosclerotic damage as manifested by cardiac disease (93%), cerebrovascular disease (38%) or renal insufficiency (78%). Operative management consisted of a unilateral procedure in 100 patients, bilateral procedures in 130 patients, including 26 nephrectomies. Simultaneous aortic replacement was performed in 95 patients (41%; 59 AAA and 36 occlusive disease). After surgery, there were 13 operative deaths (6%) and 13 renal artery repairs failed (4%). Hypertension was cured (9%) or improved (77%) in 86% of operative survivors. Renal function was improved in 43% and worsened in 15% of patients with nondialysis dependent renal insufficiency. Eighteen of twenty-three patients (78%) who were dialysis dependent before surgery were removed from dialysis following renal revascularization. On follow-up (mean: 29 months), we found that 28 patients died. Multivariate analysis demonstrated that preoperative congestive heart failure (p -0.007) and increased serum creatinine (p -0.001) were significant and independent predictors of death on follow-up. Estimated survival was significantly increased among patients with improved renal function after operation compared with patients unimproved. This review emphasizes the complexity of atherosclerosis in the elderly population presenting for operative management of renovascular hypertension. Despite the complexity of disease, our experience suggests that operative management is beneficial and can be accomplished with acceptable, albeit increased, risk in properly selected elderly patients. For elderly patients with renovascular disease in combination with renal insufficiency (i.e., ischemic nephropathy), improved renal function after operation may convey improved survival.