Incompetent Perforating Veins Research Articles

Role of Subfascial Endoscopic Perforator Surgery (SEPS) in Management of Perforator Incompetence in Varicose Veins : A Prospective Randomised Study.

The study was carried out to compare the efficacy of subfascial endoscopic perforator surgery (SEPS) and open subfascial ligation of perforators in varicose veins. This study was conducted on 100 patients of varicose veins from January 2006 to December 2010. Clinical scoring and color Doppler were performed in all the patients before surgery. Patients were divided into two groups: Group A and Group B alternately. Management of the perforators was done by subfascial endoscopic perforator surgery (SEPS) in Group A and by open subfascial ligation of perforators in Group B. Fifty patients were treated in each group. All the patients underwent ligation of incompetent saphenofemoral junction with stripping of long saphenous veins wherever the junction was incompetent with multiple ligation of superficial prominent veins. SEPS was done by two-port method without any tourniquet or balloon dissector. Total numbers of perforators ligated were 178 in Group A and 136 in Group B. Patients in both the groups got symptomatic relief of symptoms, but ulcer healing in 33% patients in Group A was faster as compared to Group B. However, at 3months of follow-up the ulcers healed in all the patients in both groups. Incidence of wound infection was higher in group B (16%) as compared to group A (0%). There were residual perforators in 8% of patients on color Doppler at 3months of follow-up in Group B while there was no residual incompetent perforator in Group A. Subfascial endoscopic perforator vein surgery is a safe and effective method for treating incompetent perforating veins. The number of perforators ligated in SEPS was more as compared to the open subfascial ligation group. Possibly some perforators may be missed on Doppler localization and missed ligation, which may be a cause of future recurrence in varicose veins. Early relief of symptoms in terms of ulcer healing was better in the SEPS group with less wound complication rate; however, all the ulcers healed in both the groups at 3months of follow-up. Cosmetic results were equal in both the groups. Major advantage of SEPS was less incidence of wound complications and less incidence of residual incompetent perforators. Hence, SEPS should be added for the management of perforators along with conventional surgery in varicose veins.

Subfascial Endoscopic Perforator Surgery Using Screw-Type Ports Is a Very Useful Component of a Comprehensive Treatment Program for Chronic Venous Insufficiency

Subfascial endoscopic perforator surgery (SEPS) with a two-port system utilizing screw-type ports, CO2 insufflation and an ultrasonic coagulation system, is a useful procedure that does not require burdensome apparatus and techniques. SEPS was accepted as a national advanced medical system by the Japanese Ministry of Health, Labor and Welfare in May 2009. Forty-one limbs of 35 patients with 10 active ulcers (C6) and 2 healed ulcers (C5) were treated by SEPS between February 2010 and December 2011. Thirty-three limbs had concomitant superficial vein surgery. SEPS alone was performed on 8 limbs, in 6 of which the superficial veins had already been ablated. In 2 limbs, incompetent perforating veins (IPVs) existed under the affected skin, around the scars of past surgery. All stasis ulcers of the 10 C6 limbs healed between 1 week and 14 months after SEPS (mean 2.9 months), with no ulcer recurrence during the follow-up period (2 to 24 months). IPVs under the scars were easily and safely interrupted by SEPS. SEPS is a very useful component of a comprehensive treatment program for chronic venous insufficiency, especially in patients with venous stasis ulcers and IPVs under the scars of past surgery.

Early clinical improvement in chronic venous insufficiency symptoms after laser ablation of saphenous veins

We aimed to assess the degree of improvement in chronic venous disease-related symptoms after endovenous laser ablation (EVLA) for saphenous vein insufficiency. The study was conducted as a single-center, single-arm prospective cohort study. The series was comprised of 55 limbs of 38 patients (24 [63%] females, 14 [37%] males; mean age, 45 ± 14 years; range, 22-78 years). All patients were clinically evaluated for limb pain, fatigue, heaviness, itchiness, night cramps, burning sensation, swelling, varices, and the presence of venous ulcers. Post-procedure changes in each symptom were categorized as full recovery, improvement, no change, or worsened. Clinical improvement in one or more symptoms was observed in 96% of the limbs, and full recovery from each symptom ranged from 36% to 80%. The best clinical response was observed in night cramps, with full recovery in 80% of the limbs, while the least responsive was pain, with full recovery in 36%. Overall 25% of limbs showed full recovery from all symptoms. The venous clinical severity score was significantly decreased from a median of 5 (range, 1-21) before treatment to a median of 3 (range, 0-12) after treatment (P < 0.001). A significant association was found between full recovery from pain and older age (P = 0.016) and combined ablation of both saphenous veins (P = 0.010), and between full recovery from burning sensation and the presence of new incompetent perforator veins (P = 0.048) on multivariate analysis. EVLA effectively improves clinical symptoms in patients with chronic venous disease. The degree of symptomatic improvement varies for each symptom.

Randomized Clinical Trial Comparing Two Methods for Endovenous Laser Ablation of Incompetent Perforator Veins in Thigh and Great Saphenous Vein Without Evidence of Saphenofemoral Reflux

Percutaneous ablation of incompetent perforators has been introduced as a safe and efficacious alternative. To compare two methods of treating incompetent thigh perforator and great saphenous veins (GSV). Patients with varicose veins of CEAP C2 and C3 with incompetent perforating veins (IPVs) in the thigh without evidence of saphenofemoral reflux and with obvious venous reflux from IPVs into the GSV distal to IPVs were included. Endovenous laser ablation was done using two methods (IPV ablation (IPVA) versus GSV ablation: GSVA). Their technical success rate, clinical success rate, and complications were compared at 1 week, and 1, 3, 6, and 12 months. Sixty-nine consecutive patients were randomized to IPVA (n = 34) or GSVA (n = 35). Technical success was significantly lower with IPVA than GSVA (p = .002). Clinical success, defined as continued closure of treated veins, was similar with IPVA and GSVA (96.1% vs 100% at 1 week, 100% vs 97.1% at 1 month, and 100% for both at 3, 6, and 12 months, respectively). IPVA has clinical results and complications similar to those of GSVA in individuals with C2 and C3 chronic venous disease with IPVs in the thigh combined with incompetent GSV, but its higher technical failure rate makes it difficult to choose it as the primary treatment method.

Endovenous ablation of incompetent perforating veins is effective treatment for recalcitrant venous ulcers

Endovenous closure of incompetent saphenous veins has been reported to facilitate venous ulcer healing; however, there is little information about the effectiveness of perforator ablation (PA) in healing recalcitrant venous ulcers. We report our experience with PA with venous ulcers unresponsive to prolonged compression therapy. Patients with nonhealing venous ulcers of >3 months' duration underwent duplex ultrasound to assess their lower extremity venous system for incompetence of superficial, perforating, and deep veins. Patients who had either no saphenous incompetence or persistent ulcers after saphenous ablation underwent PA of incompetent perforating veins >3 mm that demonstrated reflux; initial treatment was performed on the perforator vein adjacent to the ulcer with additional incompetent veins treated if ulcer healing failed. Seventy-five ulcers with 86 associated incompetent perforating veins were treated with PA in 45 patients with CEAP 6 recalcitrant venous ulcers. Treated incompetent perforator veins were located in the medial ankle (61%), calf (37%), and lateral ankle (2%). Initial success of PA, assessed by postprocedure duplex ultrasound, was 58%; repeat ablation was 90% successful and 71% had eventual successful perforator closure. No complications (skin necrosis, infection, or nerve injury) occurred. Failure of ulcer healing with successful perforator closure occurred in 10% and was due to intercurrent illness, patient noncompliance, and patient death due to unrelated causes. Of patients who healed their ulcers, the healing occurred at a mean of 138 days; an average PA of 1.5 incompetent veins per ulcer was required for healing. Ninety percent of ulcers healed when at least one perforator was closed; no ulcer healed without at least one perforator being closed. This experience demonstrates both the feasibility and effectiveness of PA for a selected group of patients with venous ulcers who fail conventional therapy with compression.

Subfascial Endoscopic Perforator Surgery in Perforator Vein Insufficiency

Surgical treatment of incompetent perforating veins of the lower leg performed by open method carries considerable morbidity and also associated with poor wound healing. Subfascial endoscopic perforator surgery (SEPS) is a new, minimally invasive endoscopic technique performed in patients with advanced chronic venous insufficiency. This technique offers an effective treatment alternative which avoids the lengthy incisions of the classical open Linton subfascial ligation techniques. The favorable ulcer healing rate and improvement in clinical symptoms suggest that SEPS is a feasible, safe and effective treatment of the incompetent perforator veins in patients with advanced chronic venous insufficiency.

Endoscopic anatomy of perforating veins in chronic venous insufficiency of the legs: “Solitary” incompetent perforating veins are often actually multiple vessels

We have already reported on the effectiveness of subfascial, endoscopic, perforating-veins surgery for chronic venous insufficiency of the legs. The incompetent perforating vein (IPV) often appears to be a single vessel, when it is actually two or more vessels. Accordingly we examined the anatomy and features of IPVS. The features of perforating veins were assessed in 173 limbs of 152 patients. In the recent 50 limbs, 128 IPVs were subjected to complete dissection of the adventitia to confirm the number of vessels. Ninety-seven out of 110 IPVs (88.2%) had a concomitant artery. On endoscopy 128 IPVs could be classified into seven types (type N, type O, type I, type II, type III, type IV, and type V) according to the combination of arteries and veins which were presented. Type N means a normal perforator consisting of a single artery with a pair of normal veins running alongside it. Type O has the same anatomy as type N but shows reverse flow. Type I has an incompetent vein with thick walls and reverse flow, which is not accompanied by an artery. Type II is an artery associated with an incompetent vein. Type III is composed of an artery, a normal vein, and an incompetent vein. Type IV is an artery with two incompetent veins and type V contains multiple incompetent veins. When the anatomy of 128 IPVs was confirmed, the number of each type was as follows: 7 type O (5%), 32 type I (25%), 1 type II (1%), 48 type III (38%), 39 type IV (30%), and 1 type V (1%). This is the first report on all the components of IPVs directly visualized in vivo. It has been almost impossible to predict the postoperative reversibility of IPVs after surgical ablation of superficial veins. By using our classification of IPVs, it will be possible to treat only the irreversible (true) incompetent veins and to avoid operating on arteries, normal veins, and reversibly incompetent veins. In the future, it will be necessary to devise the operative strategy according to the type of IPVs as assessed by endoscopic examination.

Incompetent perforating veins of the foot

The perforating veins (P.V.s) of the foot have been known among phlebologists. However, thus far, few reports have been published regarding this subject. Forty-two cases of P.V.s of the foot are presented. Their prevelant anatomical location was recognized. Diagnostic method and criteria were investigated by various technologies. It was established that Doppler-Ultrasound (D.U.) with proper isolation technique for local perforating veins is the diagnostic method of choice over Color Flow Duplex Imaging (C.F.D.I.). C.F.D.I. alone would have missed twenty-four percent of clinically incompetent P.V.s of the foot. This suggests that incompetent P.V.s can be very small and can often escape detection by duplex imaging. Over ninety percent of P.V.s of the foot are associated with superficial venous reflux of the leg. This may suggest that the etiological factor for development of P.V.s of the foot is secondary to outflow resistance.

Technical procedure of two-port system subfascial endoscopic perforator vein surgery (TPS-SEPS)

It has long been noted that incompetent perforating veins contribute to the development of chronic venous insufficiency and recurrent varicose veins that are complicated by skin ulcerations or liposcleroderma. For these conditions, severing of incompetent perforating veins is an effective surgical treatment. However, severing of incompetent perforating veins by a direct approach has become less commonly performed because of the excessive invasiveness of the procedure itself. We referred to 37 cases (44 legs) of varicose veins with or without active venous dermatitis, who underwent the two-port system subfascial endoscopic perforator surgery, which we devised (hereafter referred to as TPS-SEPS). According to this method, incompetent perforating veins can be severed without surgical intervention in the lesion. The criteria for insufficiency of the perforating veins (IPVs) are reverse flow demonstrated on a color-flow duplex and a caliber more than 3 mm in diameter. One hundred forty one out of one hundred fifty two IPVs were processed. A mean of 3.21 perforating veins per patient was severed using ultrasonic coagulation-incision apparatus. From these 37 cases we conclude that TPS-SEPS provides a useful tool for the surgeon interested in treating severe chronic venous insufficiency same as the single-port technique. Our TPS-SEPS is a relatively simple operation, but its skill is dependable and provides lower invasiveness than other operation procedure. From now on, it is necessary to unify the authorized name of the endoscopic surgery of perforating veins and is also important to define the indication of this method for the primary varicose veins without stasisdermatitis.

Management of varicose veins from chronic venous insufficiency

Chronic venous insufficiency is a progressive disease, which may require surgical intervention to prevent complications. This study was done to determine the usefulness of a high ligation with sclerotherapy to prevent the return of symptoms. Duplex scanning was used to locate incompetent veins. There was no evidence of incompetent perforating or deep veins in the 322 patients who had 483 high ligations of the greater saphenous vein. Multiple phlebectomies and limited vein stripping were done for large (>20 mm) varicose veins. The clinical, etiologic, anatomic and pathophysiologic (CEAP) score evaluated the severity of venous dysfunctions. Symptoms of leg aches, ankle edema, night cramps or ulceration were evaluated after 1–3 months, and then at 6–12 month intervals. Sclerotherapy of the saphenous vein, using a sodium tetradecyl sulfate solution from 0.1–3.0%, was done if there was no significant improvement of a non-healing ulcer or the recurrence of symptoms. Compression hose, 30–40 mm Hg, was prescribed unless contraindicated by arterial occlusive disease, acute deep vein thrombosis or severe congestive heart disease. After the high ligation, symptoms improved in 212 limbs, were unchanged in 187 limbs and became worse in 84 limbs. After sclerotherapy in 264 limbs, 237 limbs improved, 21 remained unchanged and six became worse. Patients who have varicose veins from superficial venous incompetence can achieve a good long-term outcome with the high ligation procedure. However, it is important to control venous reflux and the related symptoms with sclerotherapy as needed.

Radio-frequency stylet ablation for incompetent perforating veins

Radio-frequency stylet ablation for incompetent perforating veins

Prevalence of Chronic Venous Disorders Among Employees Working in Prolonged Sitting and Standing Postures

Research was conducted to determine the prevalence and severity of chronic venous disorders (CVD) among people working in prolonged sitting or static standing postures. Clinical examination and duplex Doppler sonography were performed on 126 employees working in a sitting (96 individuals) or a standing posture (30 individuals). Evidence of CVD was found in 59.4% of individuals working in a sitting posture and in 83.4% of those working in a standing posture, and was significantly higher in employees working in a standing posture (p = .015). Incompetent perforating veins and vena saphena magna valves, and bilateral changes were the more frequent signs of CVD. The investigation showed that prolonged standing and sitting at work increases risk of developing CVD. Further, people working in a standing posture are at a significantly greater risk for CVD than those working in a prolonged sitting posture. They should thus be the subject of specific prophylaxis interventions.

The Rationale for the Treatment of Perforating Veins in Advanced Chronic Venous Insufficiency

Treatment of incompetent perforating veins (IPVs) remains controversial in chronic venous insufficiency (CVI), because the evidence of its efficacy is of moderate quality and is not supported by prospective randomized trials without important limitations. In an excellent review of the subject, O’Donnell 1 recently concluded that the role of IPV ablation alone or concomitant with ablation of the great saphenous vein remains uncertain and awaits results of properly conducted randomized and controlled trials. Incompetent perforating veins, however frequently contribute to hemodynamic alterations in CVI. The size of perforating veins increases in patients with increasing severity of chronic venous disease (CVD), likely due to the elevated venous volume and venous pressures. There is a correlation between the number and size of IPVs and the severity of CVI. Also, the duration of reflux is longer in patients with more advanced disease. Documenting the hemodynamic significance of IPVs is difficult, because isolated IPVs cause CVD in less than 5% of patients. It is estimated that about 70% of IPVs in patients with CVD have hemodynamic significance. Evidence of Clinical Benefit From Perforator Interruption Patients with advanced CVI with duplex evidence of IPVs and patent deep veins are candidates for perforator interruption, either combined with superficial ablation or used as a staged procedure. Although initially performed with an open surgical technique, this has been replaced by several minimally invasive approaches, including subfascial endoscopic perforator surgery and percutaneous ablation using sclerosants or thermal mechanisms.

The Rationale for Ablation of Incompetent Perforating Veins Is Not Substantiated by Current Clinical Evidence

Radiofrequency ablation (RFA) is increasingly being employed for treatment of perforator vein insufficiency and venous ulcer healing. Previous studies have shown a closure rate of 60% to 80% in incompetent perforator veins (IPVs) with RFA. The purpose of the study was to determine the utility of a redo RFA for symptomatic recanalized perforators and to predict factors associated with recanalization.A retrospective analysis of 642 procedures in 256 patients with venous insufficiency due to IPVs from 2009 to 2015 was conducted. All 642 procedures were performed using RFA in patients who failed to respond to initial conservative management. Postoperative duplex ultrasound scans were performed within 3 to 7 days. Successful obliteration was defined as lack of color flow on postoperative scan. Recanalization was defined as presence of reflux on duplex ultrasound in symptomatic patients in the targeted vessel at follow-up. Follow-ups were conducted every 3 months in the first year and every 6 months thereafter.Among the 642 procedures, redo ablation was performed in 52 IPVs (29 patients, 37 extremities) including 14 women, with mean age of 65 years (standard deviation [SD], ±15 years). The Clinical, Etiology, Anatomy, and Pathophysiology class of the patients was as follows: C1, 0; C2, 0; C3, 3; C4a, 11; C4b, 7; C5, 0; and C6, 16. The distribution of the targeted IPVs included the calf (40) and ankle (12). The mean maximum diameter of the targeted veins was 4.6 mm (SD, ±1.1 mm). The initial technical success rate was 64.9%. Redo procedures had an early closure rate of 67.3%. At follow-up after a mean duration of 24 months (SD, ±16.8 months), the closure rate was 65.38%. No clinical correlation was found between successful obliteration in the redo procedure and age (P = .54), sex (P = .14), clinical class (P = .82), laterality (P = .84), or location of the vein (P = .54). When data were compared to predict factors associated with a redo procedure, IPVs located in mid and distal calf areas tended to recanalize more compared with the ankle (P = .04). Temperature of the radiofrequency stylet also showed a linear association, with patients treated at 85°C having higher probability of recanalization compared with patients treated at 90°C and 95°C (P = .01).The rates of successful closure for IPVs on initial and redo procedures are comparable. The data validate the utility of performing redo perforator ablations and suggest that temperature of the radiofrequency stylet and location of the IPVs may be predictive of a successful outcome or recanalization.

Endovenous Ablation of Incompetent Perforator Veins Is Effective Treatment for Recalcitrant Venous Ulcers

Objectives: Endovenous closure of incompetent saphenous veins has been reported to facilitate venous ulcer healing; however, there is little information about the effectiveness of perforator ablation (PA) in healing recalcitrant venous ulcers. We report our experience with PA with venous ulcers unresponsive to prolonged compression therapy. Methods: Patients with nonhealing venous ulcers of >3 months' duration underwent duplex ultrasound imaging to assess their lower extremity venous system for incompetence of superficial, perforating, and deep veins. Patients who had either no saphenous incompetence or persistent ulcers after saphenous ablation underwent PA of incompetent perforating veins >3 mm that demonstrated reflux; initial treatment was performed on the perforator vein adjacent to the ulcer, with additional incompetent veins treated if ulcer healing failed. Results: Fifty-six ulcers with 74 associated incompetent perforating veins were treated with PA in 44 patients with CEAP 4 (9%), 5 (6%), and 6 (85%) recalcitrant venous ulcers. Treated incompetent perforator veins were located in the medial ankle (67 %) and calf (33%). Initial success of PA, assessed by postprocedure duplex ultrasound imaging, was 55 %; reported complications of catheter site skin necrosis (0%), infection (0%), and nerve injury (0%) did not occur. In 18% of patients, more than one procedure was required for perforator closure; 73% had eventual successful perforator closure. Failure of perforator closure occurred in 27% and was associated with intercurrent illness, patient noncompliance, and patient death from unrelated causes. Of patients whose ulcers healed, the healing occurred at a mean of 2.3 months; an average PA of 1.5 incompetent veins per ulcer were required for healing. Conclusions: This experience demonstrates both the feasibility and effectiveness of PA for a selected group of patients with venous ulcers who fail conventional therapy with compression.

Innovative Treatments in Chronic Venous Insufficiency: Endovenous Laser Ablation of Perforating Veins: A Prospective Short-term Analysis of 58 Cases

Objective To evaluate the efficacy of endovenous laser ablation of incompetent perforating veins. Study design Prospective cohort study. Patients A total of 58 perforating veins in 33 limbs of 28 patients were treated between March 2008 and February 2009 in an outpatient clinic setting. The average age was 65 years (range 30–81 years); 64% female; CEAP clinical stage C4 (67%), C5 (17%) and C6 (16%) (Clinica, Etiology, Anatomy and Pathophysiology, CEAP). Methods All patients underwent a standardised clinical examination and duplex ultrasonography. Guided by duplex ultrasonography, the perforating veins were cannulated percutaneously and tumescent local anaesthesia was given. An 810-nm diode laser was used to deliver 14 W power. Mean total energy delivered was 187 (range 87–325) J. Three months post-treatment, all patients underwent a further duplex ultrasound examination, to determine the treatment outcome. Results Occlusion of the perforating veins was achieved after 3 months in 78% of the cases. In the CEAP C6 group, four of five ulcers had healed after 6 weeks. No serious complications, including deep venous thrombosis, were encountered. Conclusions Endovenous laser therapy for treating incompetent perforating veins is a safe and technically feasible technique. The initial occlusion rate is acceptable.

Cryo Perforator Surgery With a Diamond Dust-Coated Cryoprobe

This study was conducted to determine the efficacy of cryoperforator surgery in the treatment of incompetent perforating veins with a diamond dust coated cryoprobe. Eleven patients with clinical severity class C2-C4 were enrolled in this study. Under local anesthesia, incompetent perforating veins were duplex guided treated with a diamond dust coated cryoprobe. Duplex scan was performed 4 weeks after treatment. Eleven patients with 15 incompetent perforating veins were treated with cryoperforator surgery. Distribution of incompetent perforating veins was as follows: thigh perforator, 6; leg perforators, 9. Median diameter was 4mm (range = 2.0-6.2 mm). Follow-up showed successful treatment of 3 incompetent perforating veins (20%). Distribution of perforating veins in successful treatment: thigh perforator, 1; leg perforator, 2. This study showed that cryoperforator surgery is not feasible for treatment of incompetent perforating veins. The procedure is difficult and painful with a disturbing success rate and it should be considered obsolete.

Diagnosis and Current Management of Incompetent Perforator Veins

For nearly a century, surgeons have recognized that incompetent perforator veins (IPVs) likely play a role in the development of venous pathology. Although surgical management of IPVs has improved significantly since Linton first described his approach in 1938, little evidence exists that clearly defines the role of IPV interruption as a modern treatment for complicated venous insufficiency of the lower extremity. The purpose of this article is to review the literature in an attempt to clarify the role for IPV therapies as either adjunct or independent treatment for complicated venous insufficiency. Additionally, a summary of IPV diagnosis, patient selection, and current ablative therapies will hopefully serve as a guide for surgeons who manage venous disease.

One-year outcomes of radiofrequency ablation of incompetent perforator veins using the radiofrequency stylet device

Early success treating incompetent perforator veins (IPVs) with radiofrequency ablation (RFA) and the trend to move varicose vein surgery into a walk-in walk-out service led to the design of a specific device enabling RFA of IPVs using local anaesthesia (ClosureRFS stylet). Our aim was to assess one-year outcomes of a clinical series of patients undergoing treatment with this device. Truncal reflux, where present, was treated initially, and RFA of IPVs was performed as a secondary procedure. Duplex ultrasound examinations were performed and the presence of IPVs documented. Results were compared with preoperative scans. IPVs were classified as closed, not closed/reopened or de novo. Of the 75 patients invited for follow-up, 53 attended at a median time of 14 months (range 11-25). Sixty-seven limbs were analysed (M:F 1:2.1, median age 62, range 25-81). Of the 124 treated IPVs, 101 were closed (82%). Clinical, aetiological, anatomical and pathological clinical score was improved in 49.3% limbs. IPV closure was reduced in patients with recurrent varicose veins compared with primary varicose veins (72.3% versus 87%, P = 0.056). These results demonstrate the radiofrequency stylet device to be an effective treatment for IPVs.

Evidence on Efficacy of Treatments of Venous Ulcers and on Prevention of Ulcer Recurrence

Venous ulcers affect almost 1 million people in the United States. Delayed healing and frequent recurrence result in pain, disability, decreased quality of life, and loss of working days for the patients. Compression therapy is the most effective treatment of ulcers, but compliance with conservative treatment is important, and recurrence must be prevented by treating the underlying ambulatory venous hypertension. Evidence from prospective randomized trials confirm that ulcer recurrence is decreased with superficial vein surgery. Evidence is also increasing about the superiority of endovenous interventions, such as laser or radiofrequency ablation, over the classic open surgical treatment of high ligation, division, and stripping of the saphenous vein. Well-conducted randomized trials are still needed to provide grade A evidence to justify treatment of incompetent perforating veins. Treatment of proximal venous occlusion is important, and venous stents have been effective and durable. Open surgery is only considered today for iliac or iliocaval venous obstruction if endovascular treatment is not possible or has already failed. Open surgery for deep venous incompetence is recommended in centers of excellence, although evidence to support its effectiveness is of low quality.