Do You Know 6 Hidden Stages Of Chronic Venous Insufficiency?

Learn about the different stages of Chronic Venous Insufficiency (CVI) and how to manage the condition. Get the facts on the symptoms, diagnosis, and treatment options available.

CVI is a medical issue that is frequently disregarded by healthcare providers due to a lack of understanding of its severity and effects, as well as incomplete identification of the different ways it can present as a primary or secondary venous disorder³.

Poor blood flow in the legs, known as chronic venous insufficiency, can cause a variety of symptoms ranging from minor cosmetic issues to more serious problems^2,3,4,5. This refers to various vein problems like spider veins, swollen veins, skin discoloration, and sores.

What is the Chronic Venous Insufficiency (CVI)?

CVI is a problem with your blood flow caused by faulty valves in your leg veins. This can happen in any vein, from the surface to deep inside your leg.

It reduces the speed of blood flow from your legs to your heart, which can lead to blood accumulating in your leg veins and causing bursts in the capillaries. These bursts may result in skin discoloration, pain, and ulcers if left untreated¹.

As we get older, have a family history of vein problems, stand for long periods, are overweight, smoke, don’t exercise much, have had leg injuries in the past, or have had blood clots before, we are more likely to develop chronic venous insufficiency. Women who are pregnant or have high levels of estrogen are also at risk^6,7,8.

CVI is less common in Asians than non-Hispanic whites, as found by a study that included people from different ethnicities ⁹.

50% of people have unusual blood flow in their legs, but the exact number of people with chronic venous insufficiency (CVI) varies depending on the studies conducted on different populations^6,10,11.

How Chronic Venous Insufficiency Affects the Body?

The main reason for the symptoms of CVI in the legs is high blood pressure in the veins due to problems with the valves or blockages in the flow³.

When the muscles in the foot are not moving, the pressure in the veins can be very high, up to 80-90 mmHg.

When someone has healthy veins, the pressure decreases to below 30 mmHg when they walk.

CVI can occur when any of the veins in your legs are damaged. These veins include those in your:

• Deep veins that run through your muscles
• Superficial veins that are close to your skin
• Perforating veins that connect the deep and superficial veins

In people with CVI, leg movements don’t lower venous pressure as much as they should. When the valves in the perforator veins don’t work properly, the high pressure from calf muscle movement can affect the skin’s microcirculation and the superficial veins.

This is a condition where there is high blood pressure in the veins while walking.

After experiencing deep vein thrombosis (DVT), a condition called postthrombotic syndrome can occur, which results in high blood pressure in the veins due to blockage and damage to the valves¹³.

What are the things that increase the chances of getting CVI¹⁷?

• Old age
• History of deep vein thrombosis
• Not being active or moving much
• Taking birth control pills
• Leg injury
• Hypertension

Chronic venous disease is more likely to occur in older people²⁰, those who are obese, and those with a family history of the condition^21,22.

How Many Stages of Chronic Venous Insufficiency?

CEAP (clinical, etiologic, anatomic, pathophysiological) classifications are used to stage CVI and are currently the standard. The system was created in 1994, updated in 2004, and revised again in 2020 for clarification. They are a quick way to talk about the progress of CVI¹².

The CEAP classification is a tool used to help doctors decide how to treat people with chronic venous insufficiency. It can predict how severe a person’s symptoms are and how it affects their quality of life^14,15,16.

CVI can be categorized in four different ways, but it is usually classified using the C or clinical classifications which are based on the development of the condition and can vary over time.

CVI causes discomfort, swelling, varicose veins, and changes in the skin or sores.

When you stand for a long time, your legs may feel heavy or achy. This is called venous leg discomfort. You can relieve it by raising your legs, wearing compression stockings, or walking.

Around 20% of patients with CVI don’t experience leg discomfort, even though they have other clinical features. But for approximately 10% of patients, leg discomfort is the only clinical feature they have².

Varicose veins can cause tenderness due to the swelling of the veins. Deep vein obstruction can cause venous claudication.

Swelling in the legs is a common symptom of CVI. It can be pressed down and changed throughout the day and when standing up¹⁸.

The CEAP clinical classification for CVI is as follows:

C₀

At the beginning stage of CVI, which is called C0, there are no obvious symptoms like swollen or bulging veins.

Your doctor may suggest making lifestyle changes such as exercising more and eating healthily to prevent the condition from getting worse. Losing weight can also help slow down the progression of CVI.

C1

This stage is characterized by the appearance of small, dilated veins near the surface of the skin, which are often called spider veins or telangiectasias.

People with CVI often feel like their legs are heavy and may experience swelling in the evenings. They may also have itchy, painful, or cramping legs at night³.

However, in the beginning, stages of chronic venous disease (C1-C2), there are no particular symptoms.

At the beginning of chronic venous disease, spider veins and reticular veins can appear around the ankles, which are known as “warning veins”.

Telangiectases are small veins in the skin that are wider than usual, while reticular veins are larger and deeper under the skin²³.

Although they are not conclusive evidence of CVI, they are mainly a cosmetic concern for patients^{20, 23}.

C2

Varicose veins are larger, bulging veins that are often twisted or gnarled in appearance. In this stage, the varicose veins are clearly visible and may cause discomfort or pain.

These are veins under the skin that don’t work well and are wider than 3mm²⁴.

If the problem is not fixed, the veins can become bigger and visible to the naked eye.

The occurrence of chronic venous disease and CVI varies greatly depending on the study group, classification, and approach. However, about 25% of the population has varicose veins with or without edema (CEAP stage C2-C3), while up to 5% have trophic skin changes such as leg ulcers (C4-C6)¹⁹.

C3

Edema is a condition in which excess fluid builds up in the tissues, causing swelling. In this stage, there may be noticeable swelling in the legs, but there are no visible changes to the skin.

Swelling in the legs, which goes away overnight but can become permanent if not treated, along with varicose veins, indicates the start of a condition called CVI. This condition causes blood pressure to increase and can lead to red blood cells leaking out and causing dark spots on the skin²⁵.

Long-term swelling can cause a skin condition called stasis dermatitis, which shows up as red, scaly, and sometimes itchy patches on the lower legs. People sometimes confuse it with a bacterial infection called erysipelas or cellulitis²³.

C4

As CVI progresses, the skin may begin to change color or become discolored. This can manifest as brown or reddish-brown patches or areas of pigmentation.

If chronic venous insufficiency continues, it can cause a condition called lipodermatosclerosis. This condition causes inflammation in the skin and tissue under the skin, which can lead to redness, hardening, scarring, and sometimes pain. If left untreated, it can lead to ulcers²⁶.

C5

In this stage, the patient has had a venous ulcer in the past, but it has healed.

C6

This stage is characterized by the presence of an open, non-healing ulcer on the skin, typically on the lower leg.

A venous leg ulcer is a serious problem that occurs in about 0.7% of people with CVI, mostly affecting the medial malleolus. It takes a long time to heal completely and needs prolonged wound treatment²⁰.

CVI can cause blood clots that may lead to serious problems. Sometimes, a less common condition called superficial thrombophlebitis can occur, which causes a red, painful, hard, and warm lump or cord²⁷.

Around 18-25% of patients may experience deep vein thrombosis (DVT) and about 7% may have pulmonary embolism as a result of this condition^{28, 29}.

After a deep vein blood clot, around 20 to 50 percent of patients experience postthrombotic syndrome (PTS)^{30, 31}.

PTS is a condition where the deep veins are blocked and can cause problems like faulty valves, high blood pressure in the veins, and abnormal blood flow.

It’s important to note that not all patients with CVI will progress through all of these stages, and the severity of symptoms can vary widely between individuals.

Treatment options for CVI will depend on the stage and underlying causes of the condition.

Outlook

CVI is a serious condition that can cause a lot of problems. If left untreated, it can get worse over time and lead to painful ulcers that are hard to heal. Even with treatment, the ulcers can come back if the underlying problem of high blood pressure in the veins is not addressed.

Around 60% of people with a condition called phlebitis will develop a more serious problem called deep vein thrombosis. This can cause severe bleeding. Unfortunately, surgery for this condition is not effective, and it can be very expensive for patients.

Prevention

The first step in treating CVI is to use non-invasive methods to reduce symptoms and prevent further complications and worsening of the disease³.

Compression stockings are the primary way to treat a condition without surgery or medication ³².

Wearing compression stockings can help reduce pain, swelling, and bulging veins, as well as promote the healing of venous ulcers and prevent them from coming back ^{33, 34}.

The patient needs to regularly check their skin for any damage or infections and apply moisturizer to keep it healthy.

Using moisturizers that contain lanolin can help prevent cracking and damage to very dry skin³.

Patients should be told to raise their legs to reduce swelling.

Don’t stand or sit for too long. When you are on a long car or plane journey, move your legs, feet and ankles every 30 minutes by bending and stretching them about 10 times. This will help your blood circulation in your legs. If you have to stand for a while, take frequent breaks to sit down and raise your feet.

Encourage patients to keep their weight in a healthy range and find out what might be stopping them from losing weight, like mental health problems, certain medicines that cause weight gain, or physical limitations such as knee problems.

Patients need to know that chronic venous disease is a health problem that lasts a long time. It is important to see your healthcare provider regularly and follow their treatment plan to prevent any problems.

The Bottom Line

Chronic venous disease is a common problem that happens when the veins don’t work properly and cause blockages or leaks.

Common signs are swelling and a sensation of heaviness in the legs, along with itching, discomfort, and cramps at night.

CVI staging assists doctors in determining the advancement of your condition, which in turn helps them suggest appropriate treatments. Maintaining lower stages of CVI minimizes the likelihood of skin harm and severe complications.

Compression therapy is an important treatment for long-term vein problems. It is simple to use, does not require surgery, and helps by squeezing the veins and improving the muscles that help blood flow.

Frequently Asked Questions

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