Endovascular‑First Management of Symptomatic Chronic Mesenteric Ischemia due to Superior Mesenteric Artery Atherosclerosis

Diagnostic Confirmation

Computed tomography angiography (CTA) is the primary imaging modality for documenting severe atherosclerotic stenosis or occlusion of mesenteric vessels in patients with suspected chronic mesenteric ischemia. 1
Typical clinical presentation includes post‑prandial abdominal pain, fear of eating, and unintended weight loss that correlate with imaging findings. 2
Anatomical criteria often involve severe ostial narrowing or occlusion of at least two of the three mesenteric arteries (celiac, SMA, IMA), although isolated SMA disease can also produce symptoms. 3

All symptomatic patients should be offered endovascular therapy, which is now preferred over open surgery because it yields significantly lower peri‑operative morbidity. (American College of Radiology) 2
Endovascular revascularization with covered balloon‑expandable stents targeting the SMA is the recommended first‑line treatment for chronic mesenteric ischemia caused by SMA atherosclerosis; open surgical bypass is reserved for younger patients or those unsuitable for endovascular approaches. (American College of Radiology) 4

Prioritize revascularization of the SMA as the primary target vessel when multiple mesenteric arteries are diseased. (American College of Radiology) 4
Use covered balloon‑expandable stents to achieve optimal patency and clinical outcomes. (American College of Radiology) 4
Technical success rates range from 85 % to 100 % with stent placement in experienced centers. (American College of Radiology) 3

In‑hospital complication rates are significantly lower after endovascular therapy than after open surgery (propensity‑matched studies, P = 0.006). (American College of Radiology) 2
Meta‑analysis of 18,726 patients shows that surgical approaches carry a 2.2‑fold higher risk of in‑hospital complications compared with endovascular treatment. (American College of Radiology) 4
Long‑term durability: Endovascular therapy is associated with higher rates of restenosis, recurrent symptoms, and need for re‑intervention compared with open surgery. (American College of Radiology) 2
Five‑year overall survival is higher after open repair (statistically significant, P = 0.0001), even in high‑risk cohorts, supporting its role as a second‑line option. (American College of Radiology) 4

Reserve open mesenteric bypass or endarterectomy for:
- Younger patients with longer expected life span. (American College of Radiology) 2
- Patients who are not candidates for endovascular therapy or in whom endovascular attempts have failed. (American College of Radiology) 4

Routine revascularization of asymptomatic atherosclerotic visceral artery stenosis is not advised. (European Society of Cardiology) 1
Systemic anticoagulation alone has no role in the management of chronic mesenteric ischemia before definitive revascularization. (American College of Radiology) 2

Long‑term imaging follow‑up is essential to detect restenosis early, given the higher restenosis rates after endovascular treatment. (American College of Radiology) 4

The 2024 European Society of Cardiology (ESC) guidelines, 2022 American College of Radiology (ACR) Appropriateness Criteria, 2021 Society for Vascular Surgery (SVS) guidelines, and 2025 European Society for Vascular Surgery (ESVS) guidelines all endorse an endovascular‑first strategy for symptomatic chronic mesenteric ischemia, acknowledging the lower peri‑operative risk of endovascular therapy while recognizing the superior long‑term durability of open surgery. (European Society of Cardiology; American College of Radiology; Society for Vascular Surgery) 1