Existing data in the literature lack answers to several questions about the optimal treatment of patients with advanced CVI, especially venous ulcers. There is no level I evidence to support the superiority of surgical over medical treatment and the extent of surgical intervention. Specifically, knowledge about the efficacy and applicability of SEPS is incomplete, and prospective, randomized studies are needed. In the light of present-day knowledge, all patients should undergo a trial of medical management before resorting to surgery. Patients who benefit from surgical treatment and the addition of SEPS, if indicated, are patients with ulcers resulting from PVI of the superficial and perforating veins, with or without DVI. Based on available data, these patients can be assured an 80% to 90% chance of long-term freedom from ulcer recurrence. Despite subjective symptomatic and objective clinical score improvement, the role of surgery and SEPS is controversial in patients with PT because only 50% of patients can be predicted to have long-term freedom from ulcer recurrence. Patients with ulcer recurrence after SEPS should undergo duplex scanning to exclude recurrent or persistent perforators. If these are found to be incompetent, repeat SEPS is warranted. If there is no perforator incompetence, patients should be considered for deep venous reconstruction.