Fifteen children with severe renovascular hypertension have been treated at the Mott Children's Hospital in the University of Michigan Medical Center between July 1974 and December 1980. The average age was 10.4 yr. Stenoses were of both intimal and medial fibrodysplastic types. Four patients had significant bilateral disease. Three patients had coexistent renal artery aneurysmal disease, and three others had midabdominal aortic coarctations. The most important diagnostic studies included assays of plasma renin activity and selective renal arteriography. Primary operations (11 unilateral, 4 bilateral) included 14 aortorenal by passes (13 vein grafts, 1 hypogastric artery graft), 1 vein patch angioplasty, 1 primary anastomosis, 1 aortic reimplantation, 1 partial nephrectomy (segmentectomy), and 1 arterial dilation. Four secondary operations were performed. Critical factors in pediatric reconstructive renovascular surgery include: (1) exposure through a generous transverse anterior abdominal incision, (2) systemic anticoagulation with sodium heparin, (3) end-to-end graft-to-renal artery anastomoses, (4) generous spatulation of vessels and grafts at anastomoses, (5) use of microvascular clamps, (6) use of silicon lubricants on dilators, and (7) extreme gentleness in handling all tissues. Eleven children experienced complete remission of hypertension. Four children were improved. Excellent results were attributable to carefully planned and executed reconstructive procedures.