To improve our understanding of this frequently lethal, but potentially salvageable problem, the case records of 105 patients with 138 major intra-abdominal venous injuries seen over a 4 year period (1980-1984) were reviewed. The overall mortality rate was 54%. The most frequent abdominal venous injuries and their mortality rates were inferior vena cava, 54% (28/52); portal venous system, 51% (16/31); iliac veins, 71% (20/28); renal veins, 58% (11/19); and hepatic veins, 88% (7/8). Several important prognostic factors were identified. Of 48 patients who presented to the emergency department with no obtainable blood pressure, 41 (85%) died. Forty patients presented to the operating room with a systolic pressure less than 70 mm Hg and 36 (90%) died. Of 39 patients in hypovolemic shock for more than 15 minutes initially in the ED and operating room, 31 (79%) died. Of 71 patients who received 10 or more units of blood pre- and perioperatively, 48 (68%) died. Of 41 patients with five or more associated injuries, 30 (73%) died. Seventeen had a thoracotomy before laparotomy to cross-clamp the aorta for persistent severe shock; six responded with a substantial increase in blood pressure and three survived. Of 14 others with severe persistent shock who did not have a prior thoracotomy, only one survived. Atrial-caval shunts were attempted for severe retrohepatic bleeding in six patients with no survivors. Review of these cases suggests that improved survival might be obtained with: more vigorous administration of fluids in the emergency department and operating room; quicker movement to the operating room to control bleeding; and earlier definitive management for controlling bleeding--especially with iliac and/or retrohepatic injuries. A thoracotomy to cross-clamp the aorta prior to laparotomy with severe persisting shock should be considered.