Advances in the ability to diagnose atherosclerotic stenosis of the renal arteries have increased awareness of this disorder over the past decade, and several medical specialties have become interested in its pathophysiology, diagnosis, and therapy. Improved surgical and anesthetic techniques and the development of endovascular technology have paved the way for more aggressive management of atherosclerotic renal artery stenosis. However, there is a lack of prospective data supporting this aggressive approach, and there is little agreement among physician groups concerning the appropriateness of revascularization in many patient scenarios. We will examine the available data and make recommendations about which patient groups might benefit most from renal artery revascularization (surgical or endovascular).