ROME — Even by mafia standards, his offences were heinous.

Authorities tied him to scores of murders in the 1990s, including the kidnapping, strangulation, and acid dissolution of the 12-year-old son of a mafia informant. He was involved in the murders of two of Italy’s most prominent anti-mafia prosecutors, as well as deadly explosions in Milan, Rome, and Florence, and the strangulation of a pregnant lady.

Matteo Messina Denaro, 60, the last Italian gangster tied to a horrific time in which Sicily’s “black hand” declared war on the Italian state, was quietly captured outside a clinic in Palermo on Monday after turning up under an identity for a medical appointment after 30 years on the run.

“Until this morning,” said Maurizio De Lucia, head prosecutor of Palermo, “we didn’t even know what his face looked like.”

Italian officials, including the prime minister Giorgia Meloni, who travelled to Sicily to congratulate local law enforcement, hailed the arrest as confirmation that, however slowly, justice will eventually catch up with the country’s mobsters.

Ms. Meloni told reporters in front of the Palermo courtroom, “This was a crucial struggle to win.” This represents a severe blow to organised crime.

President Sergio Mattarella of Italy, whose brother Piersanti Mattarella was murdered by the mafia in 1980 while serving as the governor of Sicily, congratulated the police and prosecutors by phone.

However, experts and even local authorities like as Mr. De Lucia, who termed the arrest “an important contribution,” were unsure of the arrest’s final impact on the Sicilian Cosa Nostra or Italy’s other still-powerful and vast organised crime syndicates.

Lirio Abbate, a Sicilian journalist who authored a book about Messina Denaro, stated, “His arrest obviously undermines the Sicilian mafia, but this is hardly a death blow.”

He said that decades of continuous police operations against the Sicilian mafia had damaged it by throwing its leaders in prison for life without parole, seizing its assets, and destroying its enterprises.

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In their stead, he said, the vicious ‘Ndrangheta syndicate of Calabria and the Camorra gangs of Campania had become the primary participants through drug and arms trafficking and other illegal activities.

“The Sicilian mafia no longer has the vast influence of ‘Ndrangheta and Camorra,” he declared. “But it is a metastasis, it keeps renewing.”

Mr. Messina Denaro was a key player, particularly after his old capos ended up dead or in prison, but he could never be the boss of bosses because, by law, the most powerful mobster had to be from Palermo.

Messina Denaro was able to rule the western Sicilian province of Trapani despite being in hiding. In addition to his bloodlust, he was renowned for his business acumen, which he used to manage assets and infiltrate legal economic organisations, such as wind energy companies. He was protected by a vast network of mobsters as well as “citizen mobsters,” the officials stated in a strong hint of corruption.

The cops had few leads to locate him. Even his physical appearance was questioned for a long time. Italian news sites have published video footage of an older man purportedly Mr. Messina Denaro driving a jeep across the Sicilian countryside, as well as sighting accounts from across Europe.

There were rumours that he underwent face surgery to conceal his identity. The only evidence the police had to work with was a 1993 recording of his voice in a Palermo court and a handwritten love letter he left for his fiancée before he went into hiding.

To restrict their search, officials created a computer-generated image of Mr. Messina Denaro based on a photograph from a family album from the 1990s and distributed it to worldwide police agencies and the media. A man from Liverpool, England was detained in the Netherlands in September 2021 after being incorrectly recognised as Mr. Messina Denaro. He was released days afterwards.

This time there was no doubt, the authorities stated. “He quickly confessed” when caught during a visit to Palermo, the island’s capital, for a medical appointment, said Paolo Guido, the prosecutor who supervised the investigation in the Palermo office.

The authorities claimed they learnt via years of inquiry and chats intercepted from the mobster’s allies that Messina Denaro had a malignancy that required particular hospital treatments.

The police then watched a national database of patients seeking such treatment and, over time, narrowed down the list to a handful of names, including one that they suspected was the mafioso’s alias.

“We whittled down the list,” Pasquale Angelosanto, a general of the Italian carabinieri police who oversees their special division, said on Monday. He said that investigators had a hunch, but “the certainty arrived this morning.”

Mr. Messina Denaro, wearing tinted spectacles, a brown leather jacket trimmed in shearling, a matching hat, and a Franck Muller watch worth around 35,000 euros, arrived at the hospital for his meeting with another guy from the Trapani region.

The police had positioned themselves at the numerous exits and stopped Mr. Messina Denaro on a side street. They examined his photo identification card, which appeared authentic and revealed his name to be Andrea Bonafede, the one they were seeking.

They inquired as to his name. “Matteo Messina Denaro,” he replied, the authorities alleged. The news organisation Corriere della Sera published online an audio recording of him allegedly providing his name to police.

The authorities reported that witnesses outside the clinic applauded the police officers, whose faces were concealed by balaclavas, who carried the suspect into a black van that departed for an undisclosed place. As the car drove away, the officers exchanged hugs and made victory signs with their fingers.

Mr. Guido, the prosecutor, adding that Mr. Messina Denaro, like other Italian citizens, was entitled to health care, but would now receive it “in prison.”

Here are the graves of Mr. Messina Denaro’s former superiors.

Salvatore Riina, the “boss of bosses” responsible for a series of savage murders of Italian prosecutors and police personnel in the 1990s, was apprehended in Palermo in 1993. He described Messina Denaro as a youthful assassin skilled at entering local business and politics. Mr. Riina died in 2017 after spending the rest of his life in prison.

Bernardo Provenzano, a Corleone family member like Mr. Riina, retreated from Mr. Riina’s fight against the state and the murders of prominent investigators and journalists. After 13 years of calmer criminal activity, he was apprehended in 2006.

A year later, Salvatore Lo Piccolo, a potential successor, was jailed.

Mr. Messina Denaro remained the lone fugitive. At age 31, he disappeared from public life. In 1998, his father, who was also a gangster, died in hiding.

Mr. Messina Denaro, a tough leader with a penchant for luxury clothing and a playboy lifestyle, avoided composing personal letters and handwritten greetings to his employees. The majority of his closest relatives have been arrested for mafia-related crimes throughout the years, yet they have never betrayed him. In recent years, however, police have arrested his friends and seized assets worth hundreds of millions of dollars, depleting his capital.

In 2020, he was given a life sentence in absentia for his role in the 1992 murders of two anti-mafia prosecutors, Giovanni Falcone and Paolo Borsellino, and the 1993 explosions that killed 10 people in Florence, Milan, and Rome.

Prosecutors claim he was also involved in the 1993 kidnapping of Giuseppe Di Matteo, a 12-year-old boy, to persuade the boy’s father to stop leaking mafia secrets to law enforcement. The remains of the youngster were later discovered dissolving in acid.