Advances in prehospital emergency care have increased the numbers of patients arriving at the hospital with immediate life-threatening trauma. This is a review of our recent 6-year experience with 161 major abdominal vascular injuries in 123 patients. The distribution by injury site and respective mortality were: 18, aortic (56%); 39, aortic branch (37%); 51, inferior vena cava (39%); 30, inferior vena cava branch (45%); and 23, portal venous system (39%). The overall death rate was 37%. Forty-six patients presented with unobtainable blood pressure and 19 (41%) survived. Left thoracotomy and temporary aortic occlusion were required in the resuscitation of 45 patients; when applied in the emergency department the salvage rate was 7%, and in the operating room, 35%. Forty-four patients had more than one major vascular injury and 17 (39% recovered, compared to a survival rate of 76% with single vascular trauma. Others have emphasized that most deaths from major abdominal vascular injury are a result of hemorrhage. In our study although 89% of mortality was due to bleeding, half occurred after control of the major bleeding sites. These findings suggest that coagulopathy, hypothermia, and acidosis are complicating factors which demand as much attention by the surgeon as the initial resuscitation and operative control classically emphasized.