Insufficiency of the subfascial short saphenous vein is a distinct clinical entity and commonly associated with deep venous insufficiency. There is a high incidence of postoperative recurrence despite established surgical therapy. Preoperative imaging in 21 patients by means of ascending and descending venography as well as color doppler and color duplex sonography revealed a concomitant deep popliteo-femoral venous insufficiency in 86% of cases. The sensitivity of non-invasive color encoded sonography was comparable to phlebography. Pathophysiologically, the association of deep venous and short saphenous insufficiency can be explained as being the result of primary or secondary (postthrombotic) valve dysfunction of the deep venous system. This is different from the findings in patients with great saphenous vein insufficiency. Surgical consequences are ligation of the vein directly at the level of the sapheno-popliteal junction without leaving a short saphenous stump, and the obligation to inform the patient about the high risk for postoperative recurrence.