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Stages of Venous Insufficiency Explained

Stages of venous insufficiency: C1: spider veins, C2: varicose veins, C3: edema, C4: skin changes, C5: venous ulcer
Chronic venous insufficiency is a progressive disease that spans several unique presentations, from spider veins and varicose veins in the early stages to skin changes and 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.

CEAP Stages of Venous Insufficiency

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
CA: Asymptomatic
CS: Symptomatic

Vein Specialist Dr. Michael Lalezarian in Los Angeles, California

Vein Specialist

Dr. Michael Lalezarian

Vein problems? We can help. No matter what stage of venous insufficiency you find yourself in, Dr. Lalezarian can help you get your legs back.

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.

5-star venous insufficiency care in Los Angeles
“He is truly dedicated, and an extraordinary physician who’s really concerned with his patients!”

Adrianne S, October 2018

Chronic Venous Insufficiency (CVI)

We’ll begin our review by first explaining why the different stages of venous insufficiency 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.

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Diagram of CEAP stages showing varicose veins, skin changes, and venous ulcers

Staging Chronic Venous Insufficiency 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.

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

Venous insufficiency stage 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

Venous insufficiency stage 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)

Venous insufficiency stage C3 indicates edema (swelling) in the leg as a consequence of varicose veins. When veins stretch and fill with blood, excess fluid leaks out of the vein and into the tissues surrounding the vein, causing the tissue to swell. Swelling can cause the leg to feel heavy and uncomfortable, and the skin may indent temporarily if you press into it with a single finger.

Stage C4a: Pigmentation or Eczema

Venous insufficiency stage C4 describes visible skin changes on the surface of the leg. In more recent revisions of the CEAP scale, stage C4 has been broken down into three distinct subcategories to more precisely describe the features of disease progression. Stage C4a indicates the presence of pigmentation and/or eczema. When blood cells leak out of the veins, they release a chemical called hemosiderin, which has a red-brown color, and it also activates melanocytes, which produce the brown melanin pigment. As inflammatory cells leak from the vein, they can also cause the skin to become red, irritated, and itchy, consistent with the symptoms of eczema.

Stage C4b: Lipodermatosclerosis or Atrophie Blanche

Venous insufficiency stage C4b indicates the presence of lipodermatosclerosis and/or atrophie blanche. 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

Venous insufficiency stage C4c describes the presence of corona phlebectatica. Corona phlebectatica is characterized by visible dark spots (“stasis spots”) and spider veins around the ankle, and abnormally dilated veins in the same region. Together, these features make the he inside of the foot appear colorful and spotted with red, blue, and purple vessels.

Stage C5: Healed Venous Ulcer

Venous insufficiency stage C5 is used to designate patients that have had a venous ulcer that is now healed. A healed ulcer tends to leave a distinct patch of new skin where the ulcer was, and is at risk of recurrence without ongoing care and healthy lifestyle habits.

Stage C6: Active Venous Ulcer

Venous insufficiency stage C6 describes an active venous ulcer. This is the final stage of the CEAP scale, indicating that venous stasis is so severe that part of the leg isn’t receiving enough circulation to sustain healthy tissue. Venous ulceration usually occurs in the “gaiter” region of the leg (from the mid-calf to the ankle bones) and consists of a red base that oozes. Venous ulcers can be mildly painful, but the pain may be relieved by raising the leg.

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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Table of CEAP venous insufficiency stages

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

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).

Vein Screening

If you’re experiencing any of the signs of symptoms of venous insufficiency, you may want to see a specialist. A brief ultrasound exam is all that’s needed to determine if your veins are responsible, and if vein treatment could help. Contact us at ProVascularMD to schedule your visit!
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References

[1] 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.
[2] 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.
[3] 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.
[4] Raffetto JD. Pathophysiology of Chronic Venous Disease and Venous Ulcers. Surg Clin North Am. 2018;98(2):337-347.

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