Tricky acute mesenteric ischemia: what can we do?

Acute mesenteric ischemia (AMI) is a life-threatening vascular disorder that demands greater clinical and research attention due to its significant morbidity and mortality risks. Clinicians should maintain a high index of suspicion for AMI in patients presenting with severe abdominal pain disproportionate to physical findings, particularly those with atrial fibrillation or recent vasoconstrictor use. In such cases, prompt computed tomography angiography is recommended as the initial diagnostic modality, given its high sensitivity, specificity, efficiency, and favorable safety profile. Multi-disciplinary treatment plays a critical role in elucidating disease etiology and guiding therapeutic decision-making. For confirmed cases of intestinal necrosis, open surgical intervention remains the gold standard. Laparoscopic exploration offers a minimally invasive alternative for assessing bowel viability while reducing unnecessary surgical trauma in equivocal presentations. In the pre-necrotic phase of intestinal ischemia, emerging endovascular therapies demonstrate increasing promise due to their minimally invasive nature and improved clinical outcomes, warranting further investigation. Continuous clinical vigilance is essential throughout management. Persistent abdominal pain or signs of peritonitis may indicate disease progression, necessitating urgent reassessment for possible ischemic necrosis and therapeutic strategy adjustments. This review synthesizes current evidence by examining AMI pathophysiology, anatomical considerations, risk factors, and diagnostic-therapeutic advancements, with an emphasis on optimizing clinical decision-making in this critical condition.