Chronic Venous Insufficiency Stages Explained
Chronic venous insufficiency stages are used to classify the venous insufficiency for treatment plans. Chronic venous insufficiency is a progressive disease that spans several unique presentations, from spider veins and leads to varicose veins, eczema, atrophie blanche, corona phlebectatics, & venous ulcers in the late stages. Disease progression can take several years if not decades, causing many patients and practitioners to dissociate the severe manifestations of end-stage venous insufficiency from the cosmetic consequences of early-stage disease.
Fortunately, the recently revised CEAP scale provides a comprehensive framework to classify the many stages of chronic venous insufficiency, and helps to explain the continuity from cosmetic to medically severe. Our vascular specialists provide an in-depth overview of the CEAP scale and the different stages of venous insufficiency in this review.
Chronic Venous Insufficiency CEAP Stages
C0: No signs of venous insufficiency
C1: Telangiectasia (spider veins) or reticular veins
C2: Varicose veins
C3: Edema (swelling)
C4a: Pigmentation or eczema
C4b: Lipodermatosclerosis or atrophie blanche
C4c: Corona phlebectatica
C5: Healed venous ulcer
C6: Active venous ulcer
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Dr. Michael Lalezarian is a double-board certified Vascular Interventional Radiologist specializing in minimally invasive vein treatments. He is a committed partner in the battle against the devastating consequences of venous insufficiency.
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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.
Chronic Venous Insufficiency Stages with the CEAP Scale
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
Stage C1: Telangiectasia or Reticular Veins
Stage C2: Varicose Veins
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
Stage C4c: Corona Phlebectatica
Stage C5: Healed Venous Ulcer
Stage C6: Active Venous Ulcer
More recent revisions of the CEAP scale also include a venous insufficiency stage C6r, where the “r” indicates a “recurrent” active ulcer following successful healing.
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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.
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 Lurie F. Passman M. Meisner M, Dalsing M, Masuda E, Welch H, Bush RL, et al. The 2020 Update of the CEAP classification system and reporting standards. J Vasc Surg: Venous and Lym Dis 2020;8:342-52.
 Vasquez MA, Rabe E, Mclafferty RB, et al. Revision of the venous clinical severity score: venous outcomes consensus statement: special communication of the American Venous Forum Ad Hoc Outcomes Working Group. J Vasc Surg. 2010;52(5):1387-96.
 Creager, Mark A., and Joseph Loscalzo.. “Chronic Venous Disease and Lymphedema.” Harrison’s Principles of Internal Medicine, 20e Eds. J. Larry Jameson, et al. New York, NY: McGraw-Hill.
 Raffetto JD. Pathophysiology of Chronic Venous Disease and Venous Ulcers. Surg Clin North Am. 2018;98(2):337-347.
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