The evaluation and management of potential arterial injuries in penetrating neck trauma are controversial. Routine surgical exploration or arteriography can be very expensive and time-consuming and can overburden available resources if used in all patients. We reviewed the records of 4035 patients seen in our trauma center during a 20-month period and identified a total of 110 patients (2.7%) with penetrating wounds to zone II of the neck; 50 were from gunshot wounds, 43 from stab wounds, 7 from shotgun injuries, and 10 from lacerations. In 42 (39%) patients there was no arteriogram or surgery based on location of the wounds or lack of any physical findings. None of these patients later had any evidence of an arterial injury. Forty-five patients (40%) had arteriograms based on proximity or a "soft" sign of vascular injury, which included evidence of significant bleeding or a stable hematoma. A total of 15 injuries to major arteries were identified: 3 common carotid, 5 internal carotid, and 7 vertebral. One patient died during initial resuscitation, and four patients went directly to surgery with no preoperative arteriogram for active bleeding and expanding hematoma (n = 1), an expanding hematoma (n = 2), and a large, stable hematoma (n = 1). Only one patient (of the 110) had a significant major arterial injury requiring surgery that was not predicted by physical findings. Nine arterial injuries were treated nonoperatively: six vertebral, two common carotid intimal flaps, and one small distal internal carotid pseudoaneurysm (diagnosed late). Three additional minor external carotid artery injuries were observed with no adverse sequelae.(ABSTRACT TRUNCATED AT 250 WORDS)