Precision-Driven Management of Great Saphenous Varicose Veins: A Narrative Review

Great saphenous vein (GSV) incompetence is common, but numerous treatment options complicate patient-treatment matching. This narrative review synthesizes evidence for major treatment modalities and presents a clinically actionable decision framework integrating clinical, anatomical, and patient-specific factors for precision therapy selection.

A comprehensive literature search was performed in PubMed, Embase, and the Cochrane Library for studies published up to May 2026, using keywords including "great saphenous vein," "varicose veins," "endovenous ablation," "thermal ablation," "nonthermal nontumescent," "patient selection," "CEAP classification," and "duplex ultrasound." We prioritized high-quality evidence including randomized controlled trials, network meta-analyses, systematic reviews, and contemporary clinical practice guidelines. Reference lists of retrieved articles were manually searched for additional studies.

Network meta-analyses and long-term randomized trials (up to 14 years) show that endovenous thermal ablation (endovenous laser ablation [EVLA] or radiofrequency ablation [RFA]) provides durable GSV closure with low recurrence. Nonthermal nontumescent techniques (cyanoacrylate adhesive closure, mechanochemical ablation) eliminate thermal nerve injury risk and are advantageous for below-knee incompetence. High ligation and stripping is an option with lower same-site recurrence but greater invasiveness. Ultrasound-guided foam sclerotherapy is inferior for truncal reflux. A structured decision framework incorporating Clinical, Etiology, Anatomy, and Pathophysiology class, duplex ultrasound findings (reflux pattern, vein diameter, and perforator involvement), patient-specific factors (age, comorbidities, nerve injury risk, future conduit need), and patient preferences is presented.

Precision management of GSV incompetence requires systematic integration of clinical severity, anatomy, and patient-centered preferences. The proposed evidence-based framework provides a practical clinical roadmap. Emerging tools, including machine learning-based prediction, bioengineered venous valves, and advanced imaging, promise further individualization.