Major abdominal vascular injuries present problems in diagnosis, exposure, and management. Combined injuries to the abdominal aorta and vena cava are particularly lethal due to extensive blood loss, difficulty in sequential exposure, and the high incidence of associated injuries. Between 1953 and December 1974, ninety-one patients required emergency operations for abdominal aortic trauma at our city-county charity hospital. Twenty-nine of these had combined injuries to the abdominal aorta and vena cava, ten of whom had either an audible bruit preoperatively or a palpable thrill at exploration suggesting acute fistulas. Twenty-three injuries were secondary to gunshot wounds. Ten were located in the suprarenal aorta and vena cava. Management involved a variety of technics including intravascular shunts, adaptive exposures, Dacron prostheses, and autotransfusion. Survival rate was 27 per cent. Sixty-two per cent of the deaths were a function of extreme difficulty in controlling hemorrhage and exposure. There were no late recurrences of arteriovenous fistulas. Successful management of acute traumatic injury to both the abdominal aorta and vena cava requires rapid, aggressive surgical management, adaptive sequential control maneuvers, and application of technics and principles developed for elective vascular surgery.