Major abdominal vascular injuries are associated with significant morbidity and mortality. They present a formidable challenge to the most experienced surgeon. Most commonly the result of penetrating trauma, hemorrhagic shock is the usual presentation, and diagnostic maneuvers are unnecessary. Conversely, a high index of suspicion is critical in diagnosing occult injuries. This article reviews the cause, diagnosis, and treatment of major abdominal vascular injuries, with an emphasis on exposures and techniques of repair. In addition, the concepts of repair versus ligation, staged laparotomy, and the abdominal compartment syndrome are discussed.