of insulin-dependent diabetes mellitus (IDDM) complicated by diabetic nephropathy and end-stage renal disease (ESRD) on hemodialysis. After a standard preoperative pre-transplant process, he was found to have a matched cadaveric donor and underwent a combined kidney and pancreas transplant. The pancreatic graft was enterically drained and the kidney was placed in the left lower abdomen in the traditional manner. The first two weeks of postoperative course were complicated by pancreatic graft thrombosis and ureteral leak, requiring pancreatectomy, right common iliac artery repair with a bovine patch, and repair of the ureteral leak with nephrostomy tube placement. After being discharged from the hospital, he had a slow recovery, requiring close monitoring and frequent follow up appointments. Fourteen months after the initial surgery, he presented to the emergency room complaining of abdominal pain after a fall. Due to concern of organ damage from blunt trauma to the abdomen, a computerized tomography scan (CT) of the abdomen and pelvis with intravenous contrast was performed which showed a pseudoaneurysm arising off the right common iliac artery with free pelvic fluid concerning for an associated leak (Figure 1). There was also demarcation of the sigmoid colon with contrast despite the lack of administration of oral contrast. No definitive fistulous tract was seen; however, an arterio-enteric fistula was highly suspected based on the history of the arterial wall patch repair. The patient remained hemodynamically stable without evidence of gastrointestinal bleeding. Vascular surgery was consult- AbstractArterio-enteric fistulas are rare but feared complications after failed enterically drained pancreatic transplants. Massive and abrupt gastrointestinal bleeding is the cardinal presentation as a result of pseudoaneurysm rupture into the bowel lumen. However, subclinical presentation of delayed arterio-enteric fistulas may represent a diagnostic challenge for surgeons and warrants a high index of suspicion. Endovascular techniques have evolved as an excellent option as a bridge to definitive treatment.