Penetrating wounds of the central vasculature are highly lethal. Ten cases of aorta-left innominate vein fistulas have been reported in the past, but most have presented late after injury. We report three successfully managed cases that had a short interval between injury and repair, and where we used cardiopulmonary bypass with total circulatory arrest. Preoperative arteriography facilitated planning the operative approach. The ready availability of complete radiologic and surgical resources at a trauma center were responsible for the successful outcome of these highly lethal central vascular injuries.