Surgical treatment of renal artery stenosis after failed percutaneous transluminal angioplasty. From 1980 to 1989, 53 patients with renovascular hypertension underwent surgical treatment after initial unsuccessful management with percutaneous transluminal angioplasty. Renal artery stenosis was due to fibrous dysplasia in 17 patients and atherosclerosis in 36. The reasons for failure of percutaneous transluminal angioplasty were inability to dilate the stenotic lesion (32 patients), acute renal arterial occlusion (2) or dissection (8) from attempted percutaneous transluminal angioplasty, and the development of recurrent renal artery stenosis after initially successful percutaneous transluminal angioplasty (11). Three patients underwent nephrectomy due to the finding of a nonviable kidney at operation. Successful surgical revascularization was achieved in 50 patients. There was no significant fibrosis or inflammation around the previously dilated renal artery. Percutaneous transluminal angioplasty necessitated performance of a more complicated revascularization operation in only 1 patient. If the kidney is viable at operation in patients treated by percutaneous transluminal angioplasty renovascular reconstruction is not more technically difficult than when done primarily and the same excellent results can be achieved. 