The results of simultaneous elective infrarenal aortic reconstruction and renovascular surgery were retrospectively reviewed in 102 patients who consecutively underwent operation. The perioperative mortality rate (0 to 54 days) was 5% (5 of 102). Renal function had returned to baseline or was improved at discharge in 89 of 97 (92%) surviving patients. The intraoperative use of renal hypothermia was an independent predictor of improved postoperative renal function, by multivariate analysis. Twenty-five of 29 (86%) patients with severe hypertension had improvement in their blood pressure on the same or fewer medications postoperatively (p=0.0005). A retroperitoneal incision was associated with less intraoperative crystalloid fluid administration (p=0.03), more rapid postoperative resumption of an oral diet (p=0.04), and better long-term survival (p=0.02) when compared with a transperitoneal incision. We conclude that the simultaneous repair of infrarenal aortic pathology and renovascular lesions is associated with an acceptable perioperative morbidity and preserves or improves renal function in the majority of patients. The frequent use of renal hypothermia and careful consideration of the route of operative exposure will lead to optimal results.