Aorto-enteric fistula (AEF) is one of the most challenging and lethal problems that a vascular surgeon manages. This rare but devastating clinical problem can be associated with a variety of different presentations ranging from occult gastrointestinal bleeding to life-threatening hemorrhage and/or sepsis. The fundamental objectives of AEF management include timely diagnosis, resuscitation, broad-spectrum parenteral antibiotics, extirpation of infected tissues/materials, and arterial reconstruction with restoration of enteric continuity. Due to the increasing utilization of endovascular implants to treat the spectrum of aortic aneurysm and occlusive disease, contemporary vascular surgeons need to be familiar with both primary and secondary AEF presentations, the latter of which may result from either previous open aortic reconstruction with prosthetic graft or endoluminal stent-graft repair. Commonly, due to severe physiological, immunological, and/or nutritional perturbations, the vascular surgeon needs to balance the risks and benefits of different remedial options to optimize the opportunity for patient survival while achieving removal of the infectious nidus, obliterating the source of hemorrhage, and restoring arterial and intestinal integrity. Several issues remain unresolved surrounding AEF management including optimal reconstruction technique and conduit selection. Therefore, a flexible approach that includes familiarity with different vascular and bowel-related reconstruction techniques is recommended such that the optimal strategy is applied for each individual patient.