Exsanguination due to hemorrhage caused death in 18 percent of patients with penetrating iliac vessel trauma. Improved survival demands earlier recognition and expedient operative control. One hundred fourteen patients were treated at a single institution during an 11 year period. Gunshot wounds were the predominant cause of injury and combined arteriovenous injury was present in 40 percent of the patients. Twenty-one of the 28 deaths were directly related to vascular injury. All deaths occurred in patients who were initially hypotensive. Seventy-six percent of patients presented with entry wounds below the umbilicus, positive abdominal examination, and hypotension. Earlier recognition is based on this triad. Failure to respond to volume repletion portends a grave prognosis, but it is often reversed by rapid operative intervention. All hypotensive patients with entry wounds below the umbilicus and positive abdominal examination should be taken immediately to the operating room for resuscitation and operation.