OBJECTIVE Surgical dogma dictates that the evaluation of all penetrating zone 1 neck injuries must include arteriography to reliably exclude arterial injury requiring operation. This study was done to determine whether patients with normal findings at physical examination (PE) and on chest radiographs (CXR) really do require arteriography to identify occult, surgically important arterial injuries. METHODS All penetrating zone 1 neck injuries in five Level I trauma centers over a 10-year period were reviewed retrospectively. Data collected included demographics, results of PE, CXR findings, other diagnostic studies done, injuries identified, need for operation, and operative findings. Arterial injury was defined as any injury to the aorta or brachiocephalic, subclavian, vertebral, or carotid arteries found on arteriography, duplex, or at operation. RESULTS Of 138 patients studied, there were 28 arterial injuries. Of the total group of 138 patients, 36 patients had normal findings at PE and on CXR. None of these 36 patients had an arterial injury. The negative predictive value of normal PE and CXR together is 100% in this series. CONCLUSIONS Patients with penetrating wounds to zone I who have no evidence of vascular injury on PE and who have normal findings on CXR may not require routine arteriography. Further study is needed to confirm these findings.