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Chronic Mesenteric Ischemia: Clinical Diagnosis, Imaging Characteristics, and Endovascular Management

Chronic mesenteric ischemia (CMI) is a complex disorder, which typically affects elderly patients who classically present with longstanding abdominal pain and nonspecific clinical symptoms, such as food aversion and weight loss. The disease progression is often gradual due to a rich collateral network, and symptoms are generally not clinically apparent until two or more primary visceral arteries are affected. Symptomatic stenosis or occlusion of the mesenteric arteries can be the result of multiple etiologies, although atherosclerosis is the most common. Given its low incidence, a high clinical suspicion is necessary for diagnosis and to prevent a delay in treatment. Multiple imaging modalities are utilized to confirm the presence of mesenteric vessel involvement and to guide treatment. While open surgical revascularization was once the definitive treatment, endovascular management has become the first-line treatment for atherosclerotic CMI. The endovascular approach with stent placement has shown excellent primary success and encouraging long-term outcomes with reduction in morbidity and mortality compared with open surgical revascularization. Although controversial, median arcuate ligament syndrome (MALS) is a less common cause of CMI, which can affect a more varied patient population. Clinical approach, imaging characteristics, and treatment for this syndrome will also be discussed.