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

1. Introduction

Truncal vein insufficiency is a common cause of symptomatic chronic venous disease and is treated by eliminating axial reflux. Available treatment modalities include endovenous thermal ablation (EVTA), such as endovenous laser ablation (EVLA) and radiofrequency ablation (RFA), non-thermal non-tumescent techniques including cyanoacrylate closure (CAC) and mechanochemical ablation (MOCA), ultrasound-guided foam or microfoam sclerotherapy, and conventional high ligation and stripping (HL/S) [1,2].

Over the last two decades, endovenous techniques have largely replaced conventional surgery as first-line treatment for truncal reflux because of their minimally invasive nature, high anatomical success, reduced postoperative morbidity, and faster recovery [1]. However, treatment outcomes may be influenced by anatomical factors, including vein diameter, tortuosity, reflux pattern, junctional anatomy, and the length of the incompetent segment.

Large-diameter truncal veins represent a clinically relevant subgroup in which optimal treatment selection remains less clearly defined. Larger vein diameter may reduce vein wall apposition, affect the distribution of thermal energy, sclerosant, or adhesive within the vein lumen, and influence the risk of incomplete closure, recanalization, recurrence, or thrombus extension [2,3]. The 2022 European Society for Vascular Surgery (ESVS) guidelines consider truncal veins >12 mm as large-diameter veins, although published studies have used heterogeneous thresholds ranging from >8 mm to >20 mm [1,2,3].

Despite the increasing use of endovenous and non-thermal techniques, evidence specifically addressing the treatment of large-diameter truncal veins remains scattered across different modalities, study designs, and diameter definitions. The aim of this review was therefore to summarize the available evidence on treatment outcomes in large-diameter truncal veins and to compare treatment modalities with regard to vein diameter, anatomical success, recurrence, reintervention, and complications.

2. Materials and Methods

2.1. Literature Search and Eligibility Criteria

A comprehensive literature review was conducted to identify studies evaluating the treatment of large-diameter truncal veins. The PubMed/MEDLINE database was searched for studies published between January 2000 and June 2026 using the following terms, either individually or in combination: “large diameter saphenous vein”, “large great saphenous vein”, “large saphenous vein AND EVLA”, “large saphenous vein AND radiofrequency ablation”, “large saphenous vein AND cyanoacrylate”, “large saphenous vein AND mechanochemical ablation”, “large saphenous vein AND stripping”, and “large diameter truncal vein”. An additional broad search using the terms “saphenous vein AND 12 mm” and “saphenous vein AND 10 mm” was performed to identify studies that used diameter-based inclusion criteria without explicitly referring to large-diameter veins.

Reference lists of relevant publications were manually reviewed. In addition, the systematic reviews by Athavale et al. and Bontinis et al. were used for cross-referencing and identification of further potentially eligible studies [2,3].

2.2. Study Selection and Exclusion Criteria

The initial PubMed/MEDLINE search yielded 3,211 records. After removal of duplicates, 2,900 unique articles underwent title and abstract screening. Potentially relevant articles were reviewed in detail according to the predefined eligibility criteria. Following detailed assessment and cross-referencing of relevant reviews, 23 primary studies met the inclusion criteria and were included in the qualitative synthesis. A total of 30 potentially relevant studies were excluded from the primary synthesis or retained only for discussion.

Studies were eligible if they specifically investigated treatment outcomes in incompetent great saphenous veins (GSV), small saphenous veins (SSV), or accessory saphenous veins that were explicitly described by the authors as large-diameter, large-caliber, very large, enlarged, or wide-diameter truncal veins, or if treatment of large veins constituted the primary objective of the study. Thermal ablation techniques, including EVLA and RFA, non-thermal techniques, including ultrasound-guided foam sclerotherapy (UGFS), microfoam ablation, MOCA, and CAC, and conventional HL/S were considered.

Where multiple publications described the same patient cohort, the study with the longest follow-up or the most comprehensive outcome reporting was selected. Studies evaluating unselected populations with truncal venous insufficiency without a predefined focus on large-diameter veins were excluded, even when vein diameter was reported as a secondary predictor of treatment outcome. Studies reporting treatment of localized aneurysmal changes or focal saphenous vein aneurysms without evaluation of diffuse large-diameter truncal venous incompetence were also excluded. Reviews, editorials, case reports, technical notes without clinical outcome data, animal studies, studies involving venous bypass grafts, studies addressing non-truncal venous pathology, and studies of treatment modalities outside the predefined scope were excluded.

2.3. Data Extraction and Evidence Synthesis

Data extraction focused on study design, patient and vein characteristics, definition of large-diameter veins, treatment modality, follow-up duration, anatomical success, occlusion, recanalization, recurrence, reintervention, and treatment-related complications. Extracted complications included deep vein thrombosis (DVT), endothermal heat-induced thrombosis (EHIT), thrombus extension, pulmonary embolism, and other reported adverse events.

Owing to substantial heterogeneity in study design, vein diameter definitions, anatomical measurement sites, treatment protocols, follow-up duration, and outcome reporting, a quantitative meta-analysis was not performed. The evidence was synthesized narratively and grouped according to treatment modality: EVTA, UGFS/microfoam ablation, CAC, MOCA, and HL/S.

Figure 1. Search strategy and study selection flow diagram. Flow diagram showing record identification, duplicate removal, title/abstract screening, detailed assessment, cross-referencing, and final inclusion of primary studies in the qualitative synthesis.

Figure 1. Search strategy and study selection flow diagram. Flow diagram showing record identification, duplicate removal, title/abstract screening, detailed assessment, cross-referencing, and final inclusion of primary studies in the qualitative synthesis.

2.4. Study Classification and Risk-of-Bias Assessment

Included primary studies were classified according to study design, including comparative observational studies, prospective observational studies, retrospective observational studies, registry/database studies, and case series. This classification was used to describe the overall level of evidence available for the treatment of large-diameter truncal veins.

Given the heterogeneity of the available literature and the narrative objective of this review, a formal risk-of-bias assessment was not performed. The review was conducted as a structured comprehensive review rather than a systematic review or meta-analysis.

2.5. Definition of Large-Diameter Veins

No universally accepted definition of a large-diameter truncal vein exists. The 2022 ESVS Clinical Practice Guidelines consider truncal veins >12 mm in diameter as large-diameter veins [1]. Consequently, studies were included according to the definitions used by the original investigators. Across the included studies, definitions of large-diameter truncal veins were heterogeneous, with reported thresholds ranging from >8 mm to >20 mm depending on study design, treatment modality, anatomical measurement site, and investigator definition.

3. Results

3.1. Evidence Level of Included Studies

The literature search identified 3,211 records. After removal of duplicates, 2,900 unique records underwent title and abstract screening. Following detailed assessment and manual cross-referencing, 23 primary studies met the predefined inclusion criteria and were included in the qualitative synthesis. The included evidence consisted of seven comparative treatment or protocol studies, ten diameter-comparison observational cohort studies, one prospective observational study, four observational case series or technical series, and one registry/database study. No randomized controlled trial specifically designed to evaluate treatment outcomes in large-diameter truncal veins fulfilled the final inclusion criteria (Table 1).

Of the 23 included primary studies, 21 included an EVTA arm or evaluated EVTA outcomes. Two studies evaluated foam-based truncal treatment using UGFS or microfoam ablation, two studies evaluated CAC, one study evaluated MOCA, and four studies included HL/S or a stripping-based surgical component. Because several comparative studies evaluated more than one treatment modality, modality counts are not mutually exclusive and do not sum to the total number of included studies. Follow-up duration ranged from 3 weeks to 48 months (Table 2).

3.2. Definitions of Large-Diameter Truncal Veins

No standardized definition of a large-diameter truncal vein was identified among the included studies. Reported diameter thresholds varied substantially, ranging from >8 mm to >20 mm, depending on the study design, treatment modality, anatomical measurement site, and original investigator definition. Florescu et al. further distinguished between large veins measuring 10–20 mm and very large veins measuring >20 mm [4].

3.3. Endovenous Thermal Ablation

Twenty-one primary studies included an EVTA arm or evaluated EVTA outcomes in large-diameter truncal veins (Table 3). These studies included EVLA, RFA, comparative EVLA/RFA studies, EVTA versus non-EVTA comparator studies, and one registry/database study [4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24]. Definitions of large-diameter veins ranged from >8 mm to >20 mm, and follow-up duration ranged from 3 weeks to 48 months. Most studies evaluated large-diameter GSVs, while selected studies also included SSVs or accessory saphenous veins.

Among studies reporting numerical anatomical outcomes for large-diameter EVTA-treated veins, occlusion, anatomical success, recurrence-free, or recanalization-free rates at the longest available follow-up ranged from 69.7% to 100%. The lowest reported long-term occlusion rate was observed in the RFA plus foam sclerotherapy cohort reported by Poschinger-Figueiredo et al. [18]. Several EVLA and RFA studies reported closure rates above 95% [4,5,7,8,13,16]. Karathanos et al. reported 24-month occlusion of 93.1% in GSVs ≥12 mm [23]. Pisharody et al. analyzed 16,937 thermal ablation procedures from the Vascular Quality Initiative Varicose Vein Module, including 3,163 procedures in large-diameter veins defined as ≥10 mm. In the large-vein cohort, recanalization occurred in 18 procedures (0.6%), corresponding to a recanalization-free rate of 99.4% at a mean follow-up of 174 days [24].

Complication reporting was heterogeneous. Chaar et al. reported two DVTs and eight EHIT or thrombus-extension events after EVLA [6]. Atasoy et al. and Dabbs et al. reported no EHIT events, while Dabbs et al. reported three DVTs [8,13]. Florescu et al. reported one subsegmental pulmonary embolism [4]. No fatal pulmonary embolism was reported in the included EVTA studies.

Figure 2. Study-by-study EVTA outcomes in large-diameter truncal veins. The figure summarizes anatomical success, occlusion, recurrence-free, or recanalization-free rates at the longest available follow-up in studies evaluating EVTA. NR indicates an included EVTA-related study without a single directly plottable exact numeric EVTA outcome. The value for Starodubtsev et al. 2015 is marked with an asterisk because it was derived as 100% minus the reported 13.3% repeat EVLA rate. For Kubat et al. 2021, values reported as >95% are displayed at 95% for plotting purposes only. For Baram et al. 2022, recurrence-free rates were calculated as 100% minus the reported recurrence rates. Abbreviations: EVLA, endovenous laser ablation; EVTA, endovenous thermal ablation; NR, not reported/not directly plottable; RFA, radiofrequency ablation.

Figure 2. Study-by-study EVTA outcomes in large-diameter truncal veins. The figure summarizes anatomical success, occlusion, recurrence-free, or recanalization-free rates at the longest available follow-up in studies evaluating EVTA. NR indicates an included EVTA-related study without a single directly plottable exact numeric EVTA outcome. The value for Starodubtsev et al. 2015 is marked with an asterisk because it was derived as 100% minus the reported 13.3% repeat EVLA rate. For Kubat et al. 2021, values reported as >95% are displayed at 95% for plotting purposes only. For Baram et al. 2022, recurrence-free rates were calculated as 100% minus the reported recurrence rates. Abbreviations: EVLA, endovenous laser ablation; EVTA, endovenous thermal ablation; NR, not reported/not directly plottable; RFA, radiofrequency ablation.

3.4. Ultrasound-Guided Foam Sclerotherapy and Microfoam Ablation

Two primary studies evaluated foam-based treatment in large-diameter truncal veins (Table 4). Barrett et al. investigated microfoam UGFS in veins with junction diameters ≥10 mm [25], while Chin et al. compared RFA with microfoam ablation in truncal veins >8 mm [21]. Follow-up ranged from 14 weeks to a mean of 24.5 months.

Barrett et al. reported that 37.5% of large veins required a second treatment, corresponding to a calculated treatment success without repeat intervention of 62.5% [25]. Chin et al. reported complete truncal vein closure in 94% after microfoam ablation and 99% after RFA at 14 weeks [21]. Common femoral vein thrombus extension occurred in 6.1% after microfoam ablation and 3.0% after RFA.

3.5. Cyanoacrylate Closure

Two primary studies evaluated CAC in large-diameter GSVs (Table 5). Kubat et al. compared CAC with HL/S, RFA, and EVLA in GSVs ≥10 mm and reported a 12-month CAC occlusion rate of 84.8% [17]. Kavala et al. compared CAC with RFA in GSVs measuring 12–16 mm and followed patients for 24 months [22].

In Kavala et al., full occlusion after CAC was 87.3% at 1 month, 85.9% at 6 months, 81.7% at 12 months, and 77.5% at 24 months. Corresponding RFA closure rates were 100%, 97.2%, 90.1%, and 90.1%, respectively. Early closure rates were significantly higher after RFA at 1 and 6 months, whereas closure rates did not differ significantly at 12 and 24 months. Complication rates were similar between groups, although DVT occurred in 2.8% after CAC and 0% after RFA. Kavala et al. defined anatomical success as complete GSV closure without signs of recanalization [22].

3.6. Mechanochemical Ablation

One primary study evaluated MOCA in large-diameter truncal veins. Pisharody et al. investigated MOCA using ClariVein in GSVs ≥10 mm [26]. At 12 months, occlusion was reported in 88.5% of limbs, corresponding to a recanalization rate of 11.5%. No major adverse events were reported.

Table 6. Study evaluating mechanochemical ablation in large-diameter truncal veins.

Study	Design	Treatment / definition	N and follow-up	Occlusion / success	Failure / complications
Pisharody et al. 2024 [26]	Retrospective cohort	MOCA / ClariVein; GSV ≥10 mm	104 limbs; 12 months	88.5%	11.5% recanalization; no major adverse events reported

Abbreviations: GSV, great saphenous vein; MOCA, mechanochemical ablation.

Table 6. Study evaluating mechanochemical ablation in large-diameter truncal veins.

Study	Design	Treatment / definition	N and follow-up	Occlusion / success	Failure / complications
Pisharody et al. 2024 [26]	Retrospective cohort	MOCA / ClariVein; GSV ≥10 mm	104 limbs; 12 months	88.5%	11.5% recanalization; no major adverse events reported

Abbreviations: GSV, great saphenous vein; MOCA, mechanochemical ablation.

3.7. High Ligation and Stripping

Three studies evaluated HL/S as a comparator treatment in patients with large-diameter GSVs (Table 7). Definitions of large veins ranged from ≥10 mm to ≥14 mm, and follow-up ranged from 12 to 48 months [10,17,20].

Shaidakov et al. reported a residual venous stump in 6.2% after HL/S and recanalization in 4.7% after RFA at 12 months [10]. Kubat et al. reported recurrence rates of 3.2% after HL/S and 5.5% after 1470-nm EVLA at 12 months [17]. Baram et al. reported Doppler-detected recurrence rates of 6% after HL/S, 6% after EVLA, and 4% after RFA at 48 months [20].

4. Discussion

Despite the widespread use of endovenous and surgical treatments for chronic venous disease, evidence specifically addressing large-diameter truncal veins remains limited. The present review identified only 23 primary studies over more than two decades, most of which were observational cohorts or case series. Study design, vein-diameter thresholds, anatomical measurement sites, treatment protocols, follow-up duration, and outcome definitions varied substantially. This heterogeneity limits direct comparison between studies and explains why dedicated randomized controlled trials specifically designed for large-diameter truncal veins remain desirable [2,3].

A major challenge is the absence of a standardized definition of a large-diameter truncal vein. Across the included studies, reported thresholds ranged from >8 mm to >20 mm, although most studies used cutoffs between 10 and 12 mm. The 2022 ESVS guidelines consider truncal veins >12 mm as large-diameter veins [1]. In addition, vein diameter was measured at different anatomical levels, including the junction, proximal thigh, mid-thigh, distal thigh, or maximum treated diameter. Because truncal vein diameter varies along its course, a single measurement may not adequately characterize the treated vein. Future studies should therefore report the anatomical level of measurement, patient position during ultrasound examination, and whether maximum or segment-specific diameters were used.

Athavale et al. and Bontinis et al. provide an important framework for interpreting treatment strategies in this subgroup. Both reviews emphasized the limited and heterogeneous nature of the evidence base [2,3]. In particular, Bontinis et al. demonstrated that increasing GSV diameter was negatively associated with anatomical occlusion after EVTA, suggesting that the relationship between vein diameter and treatment success is continuous rather than based on a single fixed threshold [3]. Therefore, large vein diameter should not be regarded as an absolute contraindication to endovenous treatment, but as a factor that should influence treatment selection and technical strategy.

When modalities are compared according to diameter range and durability, EVTA has the strongest evidence base for large-diameter truncal veins. EVLA and RFA were evaluated across the widest diameter range, including veins >8 mm, ≥10 mm, ≥12 mm, ≥15 mm, and >20 mm. Most EVTA studies reported anatomical success, occlusion, recurrence-free, or recanalization-free rates above 90% [4,5,6,7,8,9,10,11,12,13,14,15,16,17,19,20,21,22,23,24]. However, in larger veins, particularly those exceeding 12–15 mm, standard energy delivery may be insufficient. Energy delivery should therefore be increased or adapted to vein diameter and anatomical segment. This is supported by segment-based EVLA dosing, including the four-zone dosimetry model for 1940-nm EVLA, in which vein diameters are assessed at multiple anatomical levels and energy delivery is adapted accordingly [27]. The safety and efficacy of 1940-nm EVLA and the broader evidence for EVLA systems emitting at wavelengths >1900 nm have also been reported in previous studies [28,29]. This approach is particularly relevant in the proximal GSV, where diameter and reflux burden are often greatest [27,28,29]. Larger vein diameter may also increase the risk of thrombus extension or EHIT, reinforcing the importance of careful catheter positioning, adequate tumescence, diameter-adapted energy delivery, and post-procedural duplex surveillance [3,6,13,24].

The evidence for non-thermal non-tumescent techniques in large-diameter truncal veins remains less robust. Foam-based treatment and microfoam ablation were evaluated in veins >8 mm to ≥10 mm, with outcomes ranging from a calculated treatment success without repeat intervention of 62.5% to short-term closure of 94% [21,25]. CAC and MOCA have also been evaluated in large veins, but the available data remain limited. CAC showed 84.8% occlusion at 12 months in GSVs ≥10 mm in Kubat et al. [17], while Kavala et al. reported decreasing full occlusion after CAC in GSVs measuring 12–16 mm, from 87.3% at 1 month to 77.5% at 24 months, compared with 90.1% after RFA at 24 months [22]. Although CAC can therefore be used in selected large-diameter GSVs, its long-term durability appears less predictable than thermal ablation in larger veins. This is consistent with Athavale et al., who highlighted lower CAC occlusion compared with 1470-nm EVLA or RFA in large veins and emphasized the lack of long-term patency and repeat-intervention data [2]. MOCA was evaluated in one large-vein-specific study and achieved 88.5% occlusion at 12 months in GSVs ≥10 mm [26]. Based on the current evidence, CAC and MOCA may be best suited to smaller or moderately enlarged truncal veins, whereas their durability in larger veins remains insufficiently established.

HL/S remains relevant as a comparator and as a selective treatment option. In studies including veins ≥10–14 mm, reported recurrence or residual venous stump rates were low, ranging from 3.2% to 6.2% [10,17,20]. However, these outcomes were based on recurrence, Doppler recurrence, or residual stump definitions and should not be directly equated with duplex-confirmed occlusion after EVTA. Surgery may still be appropriate for very large, tortuous, aneurysmal, or catheter-unfavorable anatomy, or when durable endovenous closure is unlikely.

Overall, the available evidence supports an individualized, anatomy- and diameter-adapted treatment strategy rather than a uniform modality-based approach. Treatment selection should consider truncal vein diameter, anatomical course, tortuosity, junctional morphology, reflux pattern, patient preference, and the expected durability of closure. EVTA, non-thermal techniques, and HL/S may each have a role in selected patients, provided that treatment choice and technical execution are adapted to the anatomical situation. Future studies should use standardized diameter definitions, uniform ultrasound measurement protocols, consistent outcome definitions, and long-term follow-up to allow meaningful comparison between treatment modalities.

5. Limitations

This review has several limitations. First, the available evidence on large-diameter truncal veins remains limited and is dominated by observational studies, retrospective cohorts, registry analyses, and case series. Dedicated randomized controlled trials specifically designed to compare treatment modalities in large-diameter veins were not identified.

Second, substantial heterogeneity was present across the included studies. Definitions of large-diameter veins varied widely, and vein diameter was measured at different anatomical levels. Some studies reported maximum vein diameter, whereas others used junctional, proximal thigh, or segment-specific measurements. These differences limit direct comparison between studies.

Third, outcome reporting was inconsistent. Studies reported anatomical occlusion, technical success, recurrence, residual venous stump, recanalization, reintervention, clinical improvement, or quality-of-life outcomes. These endpoints are not equivalent and should not be interpreted interchangeably. In some studies, success rates were calculated indirectly from reported recurrence or reintervention rates, which may introduce additional uncertainty.

Fourth, follow-up duration varied considerably, ranging from short-term duplex follow-up to 48 months. Therefore, early anatomical success may not reflect long-term durability, particularly for non-thermal techniques such as CAC, MOCA, and microfoam ablation. Finally, complication reporting was incomplete and heterogeneous, precluding reliable comparison of safety outcomes between modalities.

6. Conclusions

Evidence specifically addressing the treatment of large-diameter truncal veins remains limited and heterogeneous. EVTA has the broadest evidence base in this subgroup, whereas evidence for foam-based treatment, CAC, and MOCA is less robust and long-term durability in larger veins remains uncertain. HL/S remains relevant in selected anatomical situations. Treatment should be individualized according to vein diameter, anatomy, tortuosity, reflux pattern, patient preference, and expected durability. Future studies should use standardized diameter definitions, uniform ultrasound measurement protocols, consistent outcome definitions, and long-term follow-up to clarify optimal treatment strategies for large-diameter truncal veins.