Despite advances in the management of traumatic truncal and peripheral vascular injuries, penetrating trauma to the iliac arteries carries a high mortality. Among more than 600 patients with arterial trauma seen at the Ben Taub General Hospital between January 1958 and December 1977, eighty-three had penetrating injury to the iliac arteries. Thirty-two patients (39 per cent) died within thirty days of injury, none of these dying within 48 hours of injury. Injuries were managed by resection and end-to-end anastomosis (36 per cent), lateral arteriorrhaphy (27 per cent), ligation (20 per cent), and prosthetic interposition (10 per cent). Three perigraft infections occurred with ultimate removal of the graft and ligation of the common iliac artery. Among patients with penetrating injuries who arrive alive at a hospital, iliac artery wounds result in massive intraperitoneal blood loss, in contrast to aortic injuries which frequently have a protective tamponade for a period of time. Delay in surgery, irreversible shock, dilutional bleeding diathesis, and respiratory insufficiency result in a high mortality. A high index of suspicion and prompt aggressive surgery are necessary to improve changes of survival of patients with this highly lethal injury.