Renovascular lesions affecting more than one primary or secondary renal artery branch represent a challenging therapeutic problem. Over the last 5 years, the authors have treated 20 patients with complex multi-branch renal lesions. The number of renal artery branches per kidney ranged from two to seven. The pathological etiology of the multi-branch lesion was atherosclerotic occlusive disease in ten patients, fibromuscular occlusive disease in four (two with spontaneous dissection), renal artery aneurysm in three and abdominal aortic coarctation in three. Ex vivo techniques were used in nine patients, whereas in situ reconstruction was used in 11. Ten patients had a complex procedure involving aortic or other visceral reconstruction; two patients had solitary kidneys. There was one death in the series from an intraoperative anesthetic complication. One primary nephrectomy was performed after ex vivo exploration revealed unreconstructable disease in a significant number of branches. Severe hypertension present in all the patients before surgery was cured in five patients and improved in 14 after the operation. Renal insufficiency, present in nine patients before surgery, was improved in all cases.