Which modality for which vein? A narrative review of strategic modality selection for chronic venous disease treatment.

IntroductionManagement of chronic venous disease (CVD) has shifted from high ligation and stripping (HL/S) to multiple endovenous options, yet no single technique is optimal for all anatomical patterns or patient profiles. This narrative review aimed to summarize current evidence and guideline recommendations and outline an anatomy-oriented framework for modality selection in daily practice.MethodsA non-systematic search of MEDLINE and current guidelines from the European Society for Vascular Surgery and the Society for Vascular Surgery/American Venous Forum/American Vein and Lymphatic Society was performed, focusing on comparative trials, long-term series and key reviews of HL/S, endovenous thermal techniques (TT), cyanoacrylate closure (CAC), mechanochemical ablation (MOCA) and ultrasound-guided foam sclerotherapy (UGFS). Evidence was synthesized descriptively with attention to anatomical indications, efficacy and complications.ResultsHL/S remains valuable for markedly dilated, aneurysmal or tortuous trunks, epifascial segments and junctional disease with thrombus or unfavorable anatomy, and may provide durable occlusion in very large veins. TT is the best-studied modality, achieving high occlusion rates, rapid recovery and broad applicability across typical truncal diameters, but efficacy and skin-related events are problematic in superficial or extremely large veins. CAC and MOCA, as non-thermal non-tumescent options, offer excellent periprocedural comfort and avoid thermal nerve injury, making them attractive for below-the-knee segments; however, durability appears less robust in large-diameter or long trunks and both incur higher device-related costs. CAC is uniquely associated with phlebitis-like abnormal reaction or hypersensitivity. UGFS remains a versatile option for complex recurrent varices and neovascularization but is less suitable as a first-line treatment for truncal reflux.ConclusionsNo single "gold-standard" modality suffices for all CVD presentations. An anatomy- and patient-centered strategy that deliberately deploys all available modalities or hybrid combinations based on vein diameter, depth, length and patient factors is essential to optimize occlusion and minimize complications in daily practice.