Background: Wartime vascular injury management has traditionally advanced vascular surgery. Despite past military experience, and recent civilian publications, there are no reports detailing current in-theater treatment. The objective of this analysis is to describe the management of vascular injury at the central echelon III surgical facility in Iraq, and to place this experience in perspective with past conflicts. Study Design: Vascular injuries evaluated at our facility between September 1, 2004 and August 31, 2006 were prospectively entered into a registry and reviewed. Results: During this 24-month period, 6,801 battle-related casualties were assessed. Three hundred twenty-four (4.8%) were diagnosed with 347 vascular injuries. Extremity injuries accounted for 260 (74.9%). Vascular injuries in the neck (n = 56; 16.1%) and thoracoabdominal domain (n = 31; 8.9%) were less common. US forces accounted for 149 casualties (46%), 97 (30%) were local civilian, and 78 (24%) were Iraqi forces. One hundred seven (33%) patients with vascular injury were evacuated from forward locations after treatment initiation. Fifty-four (50%) of these had temporary shunts placed. Of 43 proximal shunts placed in-field, 37 (86%) were patent at the time of our assessment. Early amputation rate was 6.6% for those extremity injuries treated for limb salvage. Perioperative mortality was 4.3%. Conclusions: This evaluation represents the first in-theater report of wartime vascular injury since Vietnam. Extremity injuries continue to predominate, although the incidence of vascular injury appears to be somewhat increased. Local forces and civilians now represent a substantial proportion of those injured. The principles of rapid evacuation, temporary shunting, and early reconstruction are effective, with satisfactory early in-theater limb salvage.