Advanced chronic venous insufficiency (CVI) is an important health problem. In Hong Kong, with its predominantly Chinese population, most patients have primary CVI because deep vein thrombosis is less common. Nevertheless, 80% of the limbs with advanced CVI had reflux in both the superficial and deep vein systems. This showed that advanced CVI in this population is a multisystem pathological condition affecting both the superficial and deep vein systems. In the present study, it was hypothesized that the abnormal hydrostatic forces in the superficial and perforating vein systems are the significant pathologic forces leading to advanced CVI, although deep vein incompetence is common. This deep vein incompetence can be contributed to significantly by venous overload as a result of superficial reflux (reflux circuit of venous overload). This is well supported by the abolition of deep venous reflux as well as significant haemodynamic improvement as measured by air plethysmography after superficial vein surgery in limbs with mixed superficial and deep venous incompetence. Recently, subfascial endoscopic perforating vein surgery (SEPS) was introduced as a minimally invasive technique to interrupt incompetent calf perforators. Preliminary local experience showed that SEPS with concomitant superficial vein surgery was associated with a 97% ulcer healing at a mean follow up of 15 months. Significant haemodynamic improvement was also shown by air plethysmography. However, recurrent ulcers were noted in 15% of the limbs. Thus, SEPS with superficial vein surgery where appropriate can be the optimal operative treatment strategy for advanced CVI in the local population, although ulcer recurrence remains a concern.