Treatment of Large-Diameter Truncal Veins: A Structured Review of Contemporary Endovenous and Surgical Modalities

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Truncal vein insufficiency can be treated with endovenous thermal ablation (EVTA), non-thermal non-tumescent techniques, ultrasound-guided foam or microfoam sclerotherapy, and high ligation with stripping. However, the optimal management of large-diameter truncal veins remains unclear. This structured review summarizes treatment outcomes in large-diameter incompetent truncal veins and compares available modalities according to vein diameter, anatomical success, recurrence, reintervention, and complications. A PubMed/MEDLINE search was performed for studies published between January 2000 and June 2026. Studies were eligible if they specifically evaluated incompetent great saphenous veins, small saphenous veins, or accessory saphenous veins described as large-diameter, large-caliber, very large, enlarged, or wide-diameter truncal veins. Twenty-three primary studies met the inclusion criteria. Definitions of large-diameter veins varied widely, ranging from >8 mm to >20 mm. EVTA represented the largest evidence base and generally showed high anatomical success, with most studies reporting occlusion, recurrence-free, or recanalization-free rates above 90%. Foam-based treatment, cyanoacrylate closure, and mechanochemical ablation were supported by fewer large-vein-specific studies, and durability in larger veins remains less certain. High ligation and stripping showed low recurrence or residual stump rates in selected comparative studies, but outcome definitions differed from endovenous occlusion endpoints. Current evidence supports individualized treatment selection based on vein diameter, anatomy, tortuosity, reflux pattern, and expected durability. Dedicated randomized trials using standardized diameter definitions and outcome reporting are needed.