Current management of chronic mesenteric ischemia: A comprehensive review

Chronic mesenteric ischemia (CMI) is an underdiagnosed condition characterized by post-prandial pain resulting from progressive mesenteric arterial stenosis. Although traditionally regarded as rare, contemporary evidence indicates a greater prevalence, particularly among elderly females. While multi-vessel involvement is considered classical, symptomatic single-vessel disease is increasingly recognized in the setting of inadequate collateral circulation. Diagnostic evaluation relies on a combination of imaging modalities including duplex ultrasonography, computed tomography angiography, magnetic resonance angiography and selective use of conventional angiography or functional studies in equivocal cases. Revascularization remains the cornerstone of definitive management. A paradigm shift toward endovascular-first strategies has occurred, driven by superior peri-operative safety, minimal invasiveness and shorter hospitalization. Endovascular therapy is indicated in most anatomically accessible lesions, especially ostial or short-segment stenoses of the celiac or superior mesenteric arteries. Covered stents are preferred in these settings due to enhanced patency. However, limitations include restenosis risk, technical failure in long-segment occlusions and contra-indications in extrinsic compression syndromes such as median arcuate ligament syndrome. Open surgical revascularization remains critical in patients with associated complex aortoiliac disease, long occlusions or failed endovascular attempts. Retrograde bypass from the iliac or infra-renal aorta is favored in high-risk patients for technical ease, while antegrade bypass from the supraceliac aorta may offer greater durability. Hybrid approaches such as retrograde open mesenteric stenting (ROMS), indicated in cases where aortic clamping is not feasible and in acute-on-chronic mesenteric ischemia with bowel gangrene, offer high technical success and favorable mid-term outcomes. Early diagnosis and tailored revascularization strategies remain central to improving long-term clinical outcomes in CMI. Continued refinement of endovascular techniques and hybrid interventions holds promise for optimizing outcomes in anatomically and physiologically diverse patient populations.