Although pseudoaneurysms after penetrating extremity trauma are well described, we describe an unusual case of residual occult aortic injury after an initial attempt at repair that was recognized on postoperative imaging. Reoperation with primary resection and end-to-end repair was accomplished successfully. Because this entity is so unusual, we review strategies to avoid and recognize its occurrence. Early imaging allows early identification of aortic pseudoaneurysms should they occur, and will preclude delayed manifestation of complications, including death. Our case illustrates the utility of such postoperative scanning. Other alternatives to primary repair or interposition grafting in management of penetrating abdominal aortic trauma, such as interventional stent grafting, are discussed.