Chronic Venous Insufficiency Stages Explained

Chronic Venous Insufficiency (CVI)

We’ll begin our review by first explaining why the different venous insufficiency stages occur. The underlying cause of venous insufficiency is a phenomenon known as venous reflux, which describes the backward flow of blood in the veins. Healthy veins have one-way valves that open to allow blood to flow towards the heart, and close to prevent flow in the opposite direction. In the case of venous reflux, vein valves malfunction and allow blood to flow backwards, causing blood to pool and pressure to increase in the affected vein.

Cosmetically, venous reflux is apparent in the form of spider veins and varicose veins, but reflux tends to affect more than just the veins themselves. When blood accumulates in the veins, it leaks out into surrounding tissues, causing the leg to become swollen and heavy. Over time, stagnant blood can also cause an inflammatory reaction, leading to fibrosis (thickening and scarring of tissue), and ulceration (breakdown of the skin) in the most severe cases. Individuals can also experience these stages of chronic venous insufficiency if they have an obstruction somewhere in their venous system, such as a blood clot (thrombosis).

To understand why venous insufficiency tends to get worse over time, the venous system in the leg can be thought of as a network of interconnected pipes. If one vein gets backed up due to reflux, the increased pressure is ‘felt’ along the length of the vein, and by the branching vessels connected to that vein.

CEAP Scale: Chronic Venous Insufficiency Stages

The CEAP scale is used to grade the severity of chronic venous insufficiency. CEAP stands for Clinical grade, Etiology, Anatomy, and Pathophysiology. Based on physical examination, individuals with chronic venous insufficiency can be graded from C0 (no signs of vein disease) to C6 (active venous ulcer). The CEAP scale helps to communicate both the clinical symptoms and the underlying cause of each stage of venous insufficiency, and has been used by vascular specialists for over 20 years. More detail on each stage is provided in the following sections. See venous insufficiency pictures.

Stage C0: No Signs of Venous Insufficiency

Venous insufficiency stage C0 describes individuals that have no outward signs of venous insufficiency. However, this designation does not rule out venous insufficiency symptoms (see section CS below).

Stage C1: Telangiectasia or Reticular Veins

Early stage venous insufficiency C1 applies when telangiectasia (spider veins) or reticular veins (small rope-like veins) are visible on the leg. These cosmetic alterations develop in the small veins just under the skin. It’s actually quite common for individuals to have stage C1 disease that never advances to more serious stages of venous insufficiency, so spider veins and reticular veins alone aren’t a cause for concern unless you’re also experiencing symptoms (see section CS below).

Stage C2: Varicose Veins

Early stage venous insufficiency C2 describes the visible presence of varicose veins. Varicose veins develop as venous insufficiency begins to affect the larger superficial veins, such as the great saphenous vein (GSV) or the small saphenous vein (SSV). Varicose veins are large (≥3 mm) and tortuous and can appear as a single coursing vein or as intermittent fluid-filled bumps along the surface of the leg.

More recent revisions of the CEAP scale also include a venous insufficiency stage C2r, where the “r” indicates that varicose veins “recur” in the years that follow successful treatment.

Stage C3: Edema (Swelling)

Stage C4a: Pigmentation or Eczema

Stage C4b: Lipodermatosclerosis or Atrophie Blanche

Venous insufficiency stage C4b indicates the presence of lipodermatosclerosis and/or atrophie blanche varicose veins. Fibrin is a key structural component of the vein, but as the vein is damaged, it can leak out and deposit into the skin. This leads to thickening and scar-like formation, making the skin feel tough and inflexible. Lipodermatosclerosis is thickening with continued red-brown coloration, but atrophie blanche is lighter or whiter in color.

Stage C4c: Corona Phlebectatica

Stage C5: Healed Venous Ulcer

Stage C6: Active Venous Ulcer

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CA: No Symptoms of Venous Insufficiency

Where the numeric CEAP scale is used to designate visible signs of venous insufficiency, the designators “CS” and “CA” are used to describe the presence or absence of non-visible venous insufficiency symptoms. CA indicates asymptomatic venous insufficiency.

CS: Symptoms of Venous Insufficiency

Where the numeric CEAP scale is used to designate visible signs of venous insufficiency, the designators “CS” and “CA” are used to describe the presence or absence of non-visible venous insufficiency symptoms. CS indicates symptomatic venous insufficiency.

Vein Screening