MOCA is an effective endovenous therapy for saphenous reflux, with high technical success rates comparable to other endovenous therapies. An advantage of MOCA is that it does not use thermal energy for vein ablation, and therefore it avoids the risk of thermal injury, does not require tumescent anesthesia, and is a single-use device which does not require an external energy source. Studies show similar or decreased procedural pain with MOCA compared to thermal endovenous ablation. Long-term durability of vein closure may be lower after MOCA, but the clinical significance of this is unclear and requires further investigation.

The potential benefits and risks of endovenous ablation versus HL/S should be agreed upon by patient and surgeon during the preoperative visit. Since HL/S is performed less frequently today, it is wise to check with the operating room staff that the equipment including vein stripper and various attachments are available on the day of operation (Figure8.1). If phlebectomies are planned at the same operative setting, the veins to be removed should be marked in the stand­ing position with a surgical marker so that there will be no disappointment with appearance postoperatively if some unrecognized unsightly veins remain. Ageneral anesthetic is preferred for HL/S, and we prefer to avoid regional, spinal anesthesia since this may induce vasodilata­tion. Intraoperative ultrasound is preferred to map the target vein and associated anatomic landmarks. The SFJ, which usually lies just medial to the superficial femoral artery and a few centimeters below the inguinal ligament, is identified through a small transverse incision facili­tated with ultrasound (Figure8.2). It is important to ligate and divide the superficial tributary veins entering the proximal GSV at the fossa ovalis. Although often inconsistent, the tributaries usually include the circumflex iliac vein, superficial epigastric vein, pudendal vein, and the ante­rior and posterior accessory veins. Leaving one or more of these veins intact can lead to recur­rence of varicosities. In patients who have a duplicated saphenous veins, care should be taken to identify the main, refluxing GSV prior to the introduction of the internal venous stripper.