Chronic ischemic lesions of the splanchnic organs are often underestimated and underdiagnosed. The etiology, therapy and prognosis of acute mesenteric ischemia can be distinguished from chronic splanchnic ischemia. Progression of underlying atherosclerosis and the polymorbidity of the aging population results in an increased prevalence of chronic mesenteric ischemia, and occlusions of splanchnic arteries are diagnosed more frequently. Due to excellent collateralization, diffuse stenotic processes may remain asymptomatic for a long time. Computed tomography angiography with 3D reconstruction is the preferred diagnostic tool, while diagnostic angiography is more often utilized in combination with endovascular treatment (catheter-derived infusion therapy, lysis, percutaneous transluminal angioplasty, stent). Duplex sonography reveals relevant insights into the hemodynamic severity of the lesion. However, the diagnostic accuracy of Duplex sonograpy is often restricted due to bowel gas and operator dependency.In this article the operative treatment of chronic intestinal ischemia is discussed and a classification for treatment stratification is proposed.