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To describe the long-term outcomes of military lower-extremity vascular injuries, and the decision making of surgeons treating these injuries.Lower-extremity vascular trauma is an important cause of preventable death and severe disability, and decisions on amputation or limb salvage can be difficult. Additionally, the complexity of the condition is not amenable to controlled study, and there is limited data to guide clinical decision making and establish sensible treatment expectations during rehabilitation.A cohort study of 554 US service members who sustained lower-extremity vascular injury in Iraq or Afghanistan (March 2003 to February 2012) was performed using the military's trauma registry, its electronic health record, patient interviews, and quality-of-life surveys. Long-term surgical and functional outcomes, and the timing and rationale of surgical decisions, were analyzed.Of 579 injured extremities, 49 (8.5%) underwent primary amputation and 530 (91.5%) an initial attempt at salvage. Ninety extremities underwent secondary amputation, occurring in the early (n = 60; <30 days) or late (n = 30; >30 days) phases after injury. For salvage attempts, freedom from amputation 10 years after injury was 82.7% (79.1%–85.7%). Long-term physical and mental health outcomes were similar between service members who underwent reconstruction and those who underwent amputation.This military experience provides data that will inform an array of military and civilian providers who care for patients with severe lower-extremity injury. While the majority salvage attempts endure, success is hindered by ischemia and necrosis during the acute stage and pain, dysfunction and infection in the later phases of recovery.Therapeutic/prognostic, level III.