Although the incidence of penetrating trauma varies widely between countries and geographic settings, it still represents a minority of overall trauma volume seen in even the busiest inner-city trauma centers. The majority of traumatic peripheral vascular injuries (50–90 %) are due to penetrating mechanisms, but these remain relatively uncommon injuries in the civilian environment. The relative infrequency of peripheral vascular trauma, particularly at any single center, results in a very limited body of experience in evaluation and management of these injuries among trauma and vascular surgeons. This is particularly concerning given the potential for mortality and devastating morbidity if these injuries are not readily identified and properly managed. Having a well-thought-out and systematic approach that takes into account the vascular injury as well as the associated injuries and other patient factors can go a long way toward making up for a lack of personal experience.

The keys to success and a good outcome in these patients are (1) rapid and early identification of the arterial injury; (2) control of any ongoing hemorrhage; (3) identification and assessment of associated injuries to major veins, bone, nerve, and soft tissues; and (4) appropriate interventions to restore perfusion and repair the injury. Although this approach appears to be simple and straightforward, each of these steps has potential pitfalls that can lead one astray if not anticipated and appreciated. In addition to the details of the vascular injury, the overall clinical status of the patient must be continuously assessed and considered when deciding on any course of intervention.