Successful management of acute mesenteric ischemia is predicated on prompt diagnosis, which still remains clinical in nature. No single radiographic test has a sensitivity or specificity reliable enough to supplant frequent and thorough physical examination and clinical judgment. Operative management requires adequate excision of clearly necrotic bowel and a high index of suspicion of borderline segments. Arterial reconstruction is best done with autogenous tissue when possible in the setting of gangrene or spillage. While diagnosis of chronic mesenteric ischemia is far more straightforward, significant controversy still remains regarding operative management with regards to the number of vessels reconstructed, direction of the graft, and choice of conduit.