Treatment of chronic mesenteric ischemia has evolved during the past two decades. Endovascular treatment has emerged as an alternative to bypass in elderly and higher-risk patients and is now the primary treatment modality for most patients with suitable lesions, independent of their surgical risk. Open surgical revascularization still has an important role for patients with more extensive disease, including those with long-segment stenosis or occlusions, small vessel diameter, multiple tandem lesions, or severe calcification. This article summarizes current concepts in the epidemiology, natural history, treatment selection, and outcomes of open and endovascular mesenteric reconstruction for chronic mesenteric ischemia.