What Are the Stages of Chronic Venous Insufficiency?

Chronic venous insufficiency (CVI) is a condition affecting the veins in your legs. At first, CVI causes very few, if any, symptoms and can be hard to spot. As CVI progresses, it can lead to symptoms like:

• pain
• swelling
• skin damage
• ulcers

Staging helps doctors pinpoint the progression of your CVI. It can be used to figure out the best treatments for you and your outlook.

CVI will be staged when you’re first diagnosed and throughout your treatment. Your doctor will do a physical examination to diagnose CVI. They’ll inspect your skin for signs of the condition such as bulging or varicose veins. They’ll also feel your skin to check for a type of swelling called edema.

Your doctor will want to review any medications you’re currently taking to make sure they’re not the cause of your swelling. They might also want to run tests to rule out other causes of edema, including:

• congestive heart failure
• liver disease
• kidney disease
• lymphedema
• diabetes
• thyroid problems and other endocrine system conditions
• cysts or growths

During this evaluation, you might also have imaging tests done. These tests can see the structure and function of your veins. They’ll allow your doctor to diagnose and stage your CVI. Specific tests might include:

• Venous duplex imaging. This test is a type of ultrasound. It uses soundwaves to see your veins and how blood flows through them.
• Air plethysmography. During this test, a healthcare professional will use a small, painless tool to measure how the swelling in your leg changes when you move it to different positions.

CEAP classifications are the current standard for staging CVI. The CEAP system was created in 1994 and updated in 2004. New revisions were made in 2020 to further clarify and refine the system. CEAP classifications are used as a quick way to discuss the exact progression of CVI.

CEAP stands for:

• C — Clinical. Clinical staging shows how the disease is affecting your body.
• E — Etiological. Etiological classification shows the cause of your CVI.
• A — Anatomical. Anatomical classification shows which veins are affected.
• P — Pathophysiological. Pathophysiological staging shows how the movement of blood is affected.

CVI can be staged using all four letters. However, it is often staged just using the C or clinical classifications. C classifications are based on the progression of the CVI and can change with time.

Let’s take a closer look at each level of clinical classification, which assess:

• swelling
• skin quality
• vein function
• ulcer formation

Here is an at-a-glance reference for what each stage means:

C0

In stage C0, there are no visible signs of CVI. You won’t have any swelling or prominent veins at this stage. Your doctor will likely recommend lifestyle changes such as increased exercise and a healthy diet, as weight loss can slow the progression of CVI.

C1

In stage C1, you’ll start to show signs of CVI. You’ll have visible veins called reticular veins that are between 1 and 3 millimeters (mm) in diameter. You may also have visible blood vessels called telangiectasias (spider veins) that are less than 1 mm in diameter.

Reticular veins are often blue or purple, while telangiectasias appear as thin red lines under your skin. At stage C1 your veins and blood vessels will be visible but not bulging.

Your doctor will still recommend lifestyle changes at this stage. They might also recommend that you start wearing compression garments on your legs. Compression garments include compression stockings, boots, and bandages. These can slow the progression of CVI, and are the primary treatment in the early stage of the condition.

C2

In stage C2, you’ll start to see varicose veins. Varicose veins are enlarged, and you’ll be able to feel them protruding under your skin.

Stage C2 has a substage called stage C2r. This stage is for varicose veins that continue to come back, even after treatment.

You’ll continue to wear compression garments and get plenty of exercise at this stage. You can also have procedures to correct your varicose veins.

Doctors might give you an injection called sclerotherapy to cause your veins to scar down. Endovenous ablation is another treatment option that uses a laser to close off your varicose veins.

C3

In stage C3, you’ll begin to have edema. Edema is swelling in your legs caused by water retention. There won’t be any changes to your skin quality in stage C3.

You’ll wear compression garments in this stage and continue to have your varicose veins treated if needed.

C4

In stage C4, you’ll experience changes to your skin along with edema. Stage C4 is broken into three further stages:

• C4a. With this stage, your skin will change on the surface. You might have red and itchy skin. You might also see small brown or grey markings on your skin.
• C4b. In C4b, you’ll have more drastic changes to your skin that can be painful. Your skin can change texture and harden or thicken in places. You might also see scar marks form along your legs.
• C4c. At this stage, you’ll have visible veins and blood vessels around your ankles. This is called corona phlebectatica

At C4, you’ll receive skin care to treat the changes to your skin, as well as continued treatment for the swelling and varicose veins.

C5

In stage C5, you’ll have open but healed areas on your skin. These open areas are called ulcers. Your treatments will focus on reducing the swelling and varicose veins to prevent further ulcers.

C6

In stage C6, you’ll have open wounds called ulcers on your legs. You’ll need wound care to help the ulcers heal. This can include medicated creams and specialized dressings. Ulcers that don’t heal can lead to serious complications such as infection.

Stage C6 has a substage called stage C6r. This stage means that this is not the first time ulcers have formed and that ulcers have come back despite treatment.

A and B classifications

Each C stage is also given an A or B classification. A means there are no symptoms, while B means symptoms are present. For example, if your legs are swollen without pain, that would be stage C3A. If you have pain along with the swelling in your legs, that would be stage C3B.

There are steps you can take to manage CVI at home. One of the primary treatments for CVI is compression stockings. You can put compression stockings on before you get out of bed in the morning to prevent swelling throughout the day.

Other tips include:

• Get plenty of exercise, especially low-impact activities like swimming, biking, or walking.
• Keep your legs elevated above the level of your heart as often as possible.
• Keep your legs clean and well-moisturized.
• Limit your salt intake.
• Eat foods that are high in fiber, such as whole grains, nuts, and avocados.
• Eat foods that are high in potassium, such as tuna, chicken, and yogurt.
• Ask a doctor about herbal remedies, such as rutin, grape seed extract, and Centella asiatica.

CVI staging helps doctors pinpoint the progression of your condition. It’s used to recommend the right treatments for you. Keeping CVI at lower stages reduces your risk of skin damage and serious complications.