Background <p>Hypertension is highly prevalent among elderly surgical patients and is associated with impaired intraoperative hemodynamic stability and an elevated risk of postoperative complications. Although mean arterial pressure (MAP) is a key determinant of organ perfusion, the optimal intraoperative MAP target for elderly hypertensive patients has not been clearly defined.</p> Methods <p>This retrospective study analyzed clinical data from elderly hypertensive patients (<i>n</i> = 354). Patients were categorized into three groups based on intraoperative MAP: 65–75 mmHg, 75–85 mmHg, and 85–95 mmHg. The incidence of severe postoperative complications was compared across groups. Univariable and multivariable logistic regression analyses were performed to identify factors associated with these complications, and a prediction model was developed.</p> Results <p>The incidence of severe postoperative complications differed among MAP groups, with the lowest rate in the 85–95 mmHg group (8.9%) and the highest in the 65–75 mmHg group (21.7%). Multivariable analysis indicated that maintaining MAP at 85–95 mmHg was independently associated with a lower risk of severe complications, whereas a history of diabetes was associated with an increased risk. The prediction model demonstrated satisfactory clinical applicability.</p> Conclusion <p>In this retrospective analysis, maintaining intraoperative MAP within 85–95 mmHg was associated with a lower incidence of severe postoperative complications in elderly hypertensive patients. These findings provide evidence for intraoperative MAP selection in this population.</p>