Tens of millions of people in the United States alone suffer from lower extremity superficial venous insufficiency. In addition to being unsightly, the majority of varicose veins are associated with symptoms which, if left untreated, can lead to venous hypertension and its sequelae. Over the past decade, increased interest in venous disorders and the development of new noninvasive diagnostic tests have contributed to tremendous advancement in the understanding and management of varicose veins. Sclerotherapy has been used effectively for many years, particularly in Europe, and remains the cornerstone of percutaneous treatment of superficial venous insufficiency. Better understanding of the mechanisms of action of sclerosing agents, standardization of treatment methods, and the use of external compression have led to improvements in the technique of sclerotherapy, with superior results and fewer complications. Surgical ligation and stripping of the greater saphenous vein has been the gold standard for treatment of saphenofemoral junction incompetence for several years. Recently, transcatheter duplex-guided sclerotherapy and other new, innovative, minimally invasive techniques have been developed. Early results have shown improved safety and efficacy of transcatheter duplex-guided sclerotherapy compared with conventional ultrasound-guided sclerotherapy for treatment of greater saphenous vein reflux. Although long-term follow-up results are not yet available, these minimally invasive endovenous techniques may offer an excellent alternative to ligation and stripping for those patients who wish to avoid surgery.