Renal artery stenoses (RASs) that are unsuspected on clinical grounds are common in patients with peripheral vascular disease. These lesions may be missed in patients with abdominal aortic aneurysms (AAAs) who undergo arteriography based on selective clinical indications alone. We reviewed 98 consecutive patients with AAAs to determine how often selective arteriography would fail to diagnose unsuspected RAS. The location and degree of RASs were noted on preoperative arteriograms, which were routinely obtained in all patients considered for AAA repair during the study period. Medical records were studied to determine the presence of selective clinical indications for preoperative arteriography (moderate to severe hypertension or renal insufficiency). Twenty-four patients had a significant (≥50% diameter loss) RAS, and 10 patients had a severe (≥75% diameter loss) RAS or renal artery occlusion. Patients with significant RAS had a higher incidence of hypertension (p = 0.035) and renal insufficiency (p = 0.018). All 10 patients with severe RASs required at least two antihypertensive medications to control their hypertension compared with 22 of 88 patients who did not have a severe RAS (p <0.001). Forty-three patients had an indication for arteriography according to selection criteria (renal insufficiency, moderate or severe hypertension, or both). No severe RASs were found in patients who did not meet the selection criteria for arteriography. Using arteriography based on the presence of hypertension requiring two or more medications for control will detect the vast majority of severe, unsuspected RASs in AAA patients.