The 70-80% mortality rate of patients with acute mesenteric ischemia (AMI) has remained unchanged over the past 40 yr. The initial results using an aggressive approach to this problem were reported. This included the earlier and more liberal use of angiography in patients at risk and the intra-arterial infusion of papaverine for the relief of superior mesenteric artery (SMA) vasoconstriction in nonocclusive and occlusive forms of AMI. Of the first 50 patients managed by this approach, 70% had AMI demonstrated by SMA angiography. Of these 35 patients, 54% survived, including 9 of 15 patients with nonocclusive mesenteric ischemia, 7 of 16 with SMA embolus, 2 of 3 patients with SMA thrombosis, and the 1 patient with mesenteric venous thrombosis. Of the 19 survivors, 17 lost no bowel or had excision of less than 3 ft of small intestine.