During a 14-month period we used a left-flank, retroperitoneal, retrorenal approach in 23 high-risk patients with abdominal aortic aneurysm (AAA). Fourteen patients underwent suprarenal/celiac cross clamp for juxtarenal/suprarenal AAA and/or associated occlusive disease. Other indications for this approach included diminished cardiac and/or pulmonary reserve, previous extensive abdominal surgery, obesity, and inflammatory AAA. There was only one death (4%) in this high-risk group and minimal operative morbidity. The flexibility afforded by this approach for high aortic exposure allowed expeditious proximal anastomoses with minimal postoperative renal dysfunction. Pulmonary complications, ileus, and pain were reduced and patient mobilization was rapid despite the complex nature of the operative procedures. We believe that this approach offers significant advantages for all cases of AAA but particularly for anatomically complex lesions and medically high-risk patients.