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Chronic mesenteric ischemia
What's new
The European Society for Vascular Surgery (ESVS) has published updated guidelines on the management of chronic mesenteric ischemia (CMI). Revascularization, at least of the superior mesenteric artery, is recommended for patients with multivessel occlusive mesenteric artery disease and CMI, and should also be considered for CMI due to isolated superior mesenteric artery or celiac artery disease. An endovascular-first approach is the preferred treatment strategy in patients with suitable anatomy who require revascularization. The use of covered stents is suggested for lesions <25 mm, and bare metal stents for lesions >25 mm. Open revascularization is suggested in fit patients after failed endovascular intervention or when endovascular treatment is not feasible or is contraindicated. .
Background
Overview
Definition
Chronic mesenteric ischemia is a clinical condition characterized by reduced blood flow to the mesenteric arteries, usually due to atherosclerotic occlusive disease at the origins of the mesenteric vessels, which can lead to ischemia to the intestinal tissues.
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Pathophysiology
The primary pathophysiological mechanism underlying chronic mesenteric ischemia is atherosclerotic occlusive disease at the origins of the mesenteric vessels. Rare causes include thromboangiitis obliterans, FMD, and aortic dissection.
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Epidemiology
Chronic mesenteric ischemia is a relatively rare condition, with a reported incidence of 9.2 per 100,000 person-years and a prevalence of 0.03%.
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Risk factors
Risk factors for chronic mesenteric ischemia include age, smoking, and comorbidities such as hypertension and diabetes. These factors contribute to the development of atherosclerosis, which in turn leads to the narrowing or occlusion of the mesenteric arteries.
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Disease course
Clinically, chronic mesenteric ischemia presents with postprandial abdominal pain, unintended weight loss, nausea, vomiting, early satiety, anorexia, and changes in bowel habits. These symptoms are progressive and can lead to fear of food due to the associated pain.
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Prognosis and risk of recurrence
The prognosis of chronic mesenteric ischemia can be severe if left untreated. Patients often develop severe malnutrition due to the associated weight loss and changes in eating patterns. Endovascular interventions have improved postoperative morbidity but have also resulted in early symptom recurrence and reintervention. Age > 80 years, diabetes, CKD stage IV or V, and home oxygen are independent predictors of any-cause mortality.
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Guidelines
Key sources
The following summarized guidelines for the evaluation and management of chronic mesenteric ischemia are prepared by our editorial team based on guidelines from the European Society for Vascular Surgery (ESVS 2025), the European Society of Cardiology (ESC 2024), the Society for Vascular Surgery (SVS 2021), the European Association for Gastroenterology, Endoscopy and Nutrition (EAGEN/CIRSE/NVMDL/HSGO/UEG/DMIS/ESGAR 2020), the American College of Radiology ...
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Screening and diagnosis
Diagnosis
As per ESVS 2025 guidelines:
Suspect chronic mesenteric ischemia in patients with chronic abdominal symptoms and ≥ 50% stenosis of the superior mesenteric artery and ≥ 50% stenosis in another mesenteric artery.
B
Consider suspecting chronic mesenteric ischemia in patients with chronic abdominal symptoms and ≥ 70% isolated superior mesenteric artery stenosis.
C
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Differential diagnosis
Diagnostic investigations
General principles
As per ESC 2024 guidelines:
Obtain assessment by a vascular team in patients with acute or chronic mesenteric ischemia.
B
Obtain a thorough clinical, vascular, and cardiovascular risk factor laboratory evaluation in patients with PAD.
B
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Diagnostic imaging
Laboratory testing
Diagnostic procedures
Medical management
Setting of care: as per ESVS 2025 guidelines, evaluate and treat patients with chronic mesenteric ischemia at specialized centers capable of offering multidisciplinary assessment and both open and endovascular revascularization.
B
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Lipid-lowering therapy
Glycemic control
Antihypertensive therapy
Nonpharmacologic interventions
Nutritional support: as per SVS 2021 guidelines, do not offer TPN as an alternative to revascularization for patients with chronic mesenteric ischemia due to the risk of clinical deterioration, bowel infarction and catheter-related complications.
D
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Lifestyle modifications
Therapeutic procedures
Indications for revascularization: as per ESVS 2025 guidelines, perform revascularization in patients with multivessel occlusive mesenteric artery disease and chronic mesenteric ischemia.
B
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Endovascular revascularization
Perioperative care
Evaluation before revascularization
As per SVS 2021 guidelines:
Ensure optimization from a medical standpoint in patients undergoing revascularization for chronic mesenteric ischemia before performing an intervention but expedite their preoperative evaluation.
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Obtain CTA to delineate the vascular anatomy before any revascularization. Consider obtaining catheter-based arteriogram as an alternative if the anatomy is not clear on CTA.
B
Surgical interventions
Surgical revascularization
As per ESVS 2025 guidelines:
Consider performing open revascularization in patients with chronic mesenteric ischemia who are fit, after failed endovascular intervention, or when endovascular intervention is not feasible or is contraindicated.
C
Consider performing retrograde open mesenteric artery stenting in patients with chronic mesenteric ischemia requiring superior mesenteric artery revascularization when an antegrade percutaneous approach is not feasible or successful.
C
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Celiac artery release
Specific circumstances
Asymptomatic patients, management
As per CIRSE/DMIS/EAGEN/…/UEG 2020 guidelines:
Perform revascularization for the prevention of acute mesenteric ischemia in asymptomatic patients with significant stenosis/occlusion of all 3 mesenteric vessels only after carefully weighing the risks and benefits of treatment, given the low level of evidence.
B
Consider performing endovascular intervention for the prevention of acute mesenteric ischemia in asymptomatic patients with significant stenosis/occlusion of ≥ 2 mesenteric vessels requiring to undergo major abdominal surgery with potential ligation of collateral circulation.
C
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Asymptomatic patients (follow-up)
Patient education
Preventative measures
Follow-up and surveillance
Post-revascularization antiplatelet therapy: as per ESVS 2025 guidelines, consider administering a short course (minimum of 1 month) of dual antiplatelet therapy with aspirin and clopidogrel to reduce the risk of stent thrombosis for patients who underwent endovascular revascularization for atherosclerotic mesenteric artery disease.
C
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Follow-up after revascularization
Management of recurrent disease (evaluation)
Management of recurrent disease (revascularization)