Controversy continues over management of major venous injuries. The records of 322 patients with venous injury were reviewed. Isolated venous injury was present in 83 patients; 54 (65%) underwent ligation of the injured vein. Combined arterial and venous injuries were present in 239 patients; 170 (71%) patients had ligation. Injured were the inferior vena cava, iliac, femoral, popliteal, distal leg, and arm veins; all were confirmed at surgery. Arterial injuries were repaired with standard techniques; venous injuries were ligated or repaired by end-to-end or lateral phleborrhaphy. Adjunctive fasciotomy was used as clinically indicated. The patients were followed an average of 32 months. No patient with isolated venous injury developed permanent sequelae, although 29 (35%) had transient extremity edema. Transient edema developed in 86 (36%) patients with combined injury, and permanent edema occurred in 4 (2%). Edema developed regardless of vein injury ligation or repair. No extremity was lost after venous injury ligation. While repair of all venous vascular injuries is still the surgical ideal, in civilian practice permanent sequelae of venous injury ligation are rare and in patients with hemodynamic instability from blood loss, extensive local injury, associated organ injury, anesthesia requirements, or other concerns venous ligation is acceptable.