Deep venous valve reconstruction addresses patients affected by chronic venous insufficiency (CVI) and deep venous incompetence (DVI). Deep venous incompetence involves three principal etiologies: secondary, primary, and congenital. Secondary venous valve incompetence (SVVI) results from post-thrombotic syndrome valve damage. Post-thrombotic syndrome (PTS) of the inferior cava system occurs in approximately two-thirds of patients affected by deep venous thrombosis (DVT). It manifests in two principal anatomic lesions: vein obstruction and valve damage, causing, respectively, outflow obstruction and deep reflux. These may be isolated or variously associated from the groin to the knee. Primary venous valve incompetence (PVVI) represents the second cause of CVI. The valve cusps are present but malfunctioning. Finally, congenital valve absence (CVA) or valve agenesis is a rare congenital condition (2%), in which the valve is either absent or rudimentary. Whatever the etiology, deep venous incompetence causes deep venous reflux, which is associated with obstruction and/or superficial and/or perforator pathology and is the most common cause of microvascular venous hypertension. The respective involvement of each system is difficult to quantify, but deep venous incompetence, when correlated with deep axial reflux, plays a crucial role. Today, several technical surgical options are available to correct deep venous reflux, ranging from valve repair to neovalve construction, which is able to improve the quality of life of affected patients.