Injuries of the inferior vena cava (IVC) require prompt and definitive action. To evaluate our current management strategy, we reviewed 38 patients with IVC trauma treated from 1983 through 1990. Sixteen were injured by gunshots, eight by stabs, and 14 by blunt mechanisms. Thirty of the 38 survived (79%). All were awake on presentation, although 45% were hypotensive (systolic blood pressure < 90 mmHg). The mean Injury Severity Score was 27. At laparotomy all demonstrated active retroperitoneal bleeding or an expanding hematoma. The caval injury was retrohepatic in 12 (three involving the hepatic veins), suprarenal in seven, pararenal in nine, and infrarenal in ten. Among the eight deaths, five had retrohepatic injuries, two pararenal injuries, and one had an infrarenal injury. Surgical repair was accomplished in 33, 26 (79%) via lateral venorrhaphy and seven via polytetrafluoroethylene patch repair. The right chest was entered with diaphragmatic division in 8 of 12 cases with retrohepatic injuries. Two atrial-caval shunts were used and both patients survived. Twenty follow-up studies (at > or = 3 months) were performed in which three patients demonstrated IVC occlusion, and one had a Budd-Chiari-like syndrome. We conclude that inferior vena caval injury remains a highly lethal injury. Successful outcome depends on prompt volume restoration, a stratified selective management approach, and avoidance of hypothermia. Prosthetic vena caval reconstruction represents an acceptable alternative.