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Chronic mesenteric ischemia (CMI) is defined by stenoses or occlusions of the celiac artery, superior or inferior mesenteric artery. While it is mostly cause by atherosclerotic disease, less frequent cause in particular in younger patients are fibrowmuscular dysplasia or vasculitis. Risk factors include smoking, hypertension, dyslipidemia, higher age, and female sex. Symptomatic CMI only accounts for less than 5 % of intestinal ischemic events. The prevalence of asymptomatic CMI is unknown but may be as high as 15 % and is more frequent in peripheral artery disease (27 %) and abdominal aortic aneurysm (40 %). The celiac artery is mostly affected. Abdominal pain that is aggravated with food intake with preserved appetite, abdominal bruits, and severe malnutrition can be important clinical hints that raise the suspicion of CMI. The diagnostic modality of choice is duplex ultrasound that should be performed in specialized centers potentially together with functional test causally linking symptoms to relevant arterial stenosis or intestinal ischemia. Typically, a stenosis of only one artery is unlikely to cause CMI. The therapy of choice is revascularization. In most cases angioplasty potentially together with stenting is performed due to low post-interventional mortality in mostly multi-morbid patients with excellent technical and clinical success rates. Non-atherosclerotic CMI in particular in younger patients may require surgery. Similar to the treatment of patients with other cardiovascular diseases, atherosclerosis of mesenteric arteries requires life style modification and optimal medical therapy for risk reduction. Platelet inhibition is indicated after revascularization., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (© Georg Thieme Verlag KG Stuttgart · New York.)