The stages of venous insufficiency

Venous insufficiency, in its best-known form represented by varicose veins, is a real disease. It's not just a cosmetic problem, which should be a secondary concern given the medical importance of this condition.
It's a progressive disease, meaning it tends to get worse, and is prone to complications, some of them serious.
In 1994, a consensus of international experts established the CEAP classification, which reflects this progressive nature, with stages of increasing severity.
Here, we'll be focusing on the clinical aspect of this classification, which describes the visible or palpable signs of the stages of evolution: the letter "C" in the CEAP classification. The letter "C" is accompanied by the letter "a" if the patient is not in pain (asymptomatic) or "s" if there is any discomfort (symptomatic: pain, heaviness, itching, etc.).

It can almost be considered a pre-stage of venous insufficiency: no visible or palpable signs of venous insufficiency are present on examination of the leg.
At this stage, however, there may be some discomfort (referred to as C0s stage), as well as disturbances in venous circulation detectable by ultrasound Duplex scan.
The C0 stage is not, however, predictive of the onset of venous insufficiency, as discomfort may have a completely different origin.

In everyday language, this is known as "spider veins".
These are tiny vessels (veins or capillaries) located just below the epidermis (the most superficial layer of the skin).
They form fine networks or circumscribed patches of varying size, forming a hair follicle in the form of a star, spider's legs or sometimes patches.

They can be of different colors, from red to dark purple, and these different colors can co-exist on the same leg.
They can also vary in size, from hair-thin to larger varicose dilatations.
They are very common (at least one in two people over the age of 50 are affected), and the majority of patients affected will never progress to the more advanced stages of venous insufficiency. The treatment of spider veins can therefore be considered to be for cosmetic purposes.
However, the patient may experience discomfort, known as stage C1s, which may lead to the prescription of a venotonic drug to relieve this discomfort.
Varicose veins are mainly treated with sclerotherapy or cutaneous laser.

Varicose veins are permanently dilated and elongated veins that no longer perform their role of draining venous blood.
They appear more or less visibly under the skin, in the form of bluish cords, balls or rosaries.
They are unsightly and often cause varying degrees of discomfort (C2s stage), with pain, discomfort, leg heaviness, fatigue, edema, itching, restless syndrome or nocturnal cramps.
Varicose veins almost always increase in diameter and spread, from existing varicose veins to new areas of the leg. This evolution towards aggravation is more or less rapid, depending on the individual fragility of patients, their lifestyle (daily trampling, exposure to heat, etc.) and their past history (multiple pregnancies).
Even in cases where varicose veins cause few or no symptoms (referred to as C2a stage), concern over their presence is not merely cosmetic (it should even be secondary), as they involve a genuine medical issue.
Not only do they have a natural tendency to worsen and spread, but they can also become complicated, with the onset of thrombosis.
This is known as "paraphlebitis" or "superficial phlebitis" (see related article), i.e. the presence of a thrombus (clot) in a varicose vein of the superficial network (in the subcutaneous tissue). Thrombosis can affect not only the varicose branches beneath the skin, but also the saphenous veins into which these branches drain. The clot present in a varicose vein can sometimes spread to the "deep" veins, i.e. the veins located in the leg muscles. Involvement of the deep veins is more worrying, as thrombosis can spread to the thigh and beyond to the abdominal veins (iliac veins and vena cava) and sometimes to the heart and lungs (pulmonary embolism).
Thrombosis occurs more frequently in high-risk situations (prolonged travel, exposure to heat, post-operative period, trauma, etc.), but is often spontaneous and unpredictable.
Wearing compression stockings, staying well hydrated, exercising and even prescribing anticoagulants (only in high-risk situations) are all factors in preventing phlebitis in the presence of varicose veins.

Thus, the C2 stage of varicose veins, which is a priori benign, needs to be taken seriously, even in the absence of discomfort, because of the risk of a negative evolution, especially as treatment at this stage can be carried out by means that are usually simple, with the ASVAL method in particular.

Venous edema in the legs is due to an accumulation of so-called "interstitial" fluid in the subcutaneous fat, causing swelling under the skin.
This accumulation of subcutaneous fluid is due to increased pressure in the veins, caused by chronic congestion.
There are several possible causes of edema (venous, lymphatic, cardiac, drug-induced or related to liver or kidney disease).
The venous origin of edema can be identified by clinical examination (presence of varicose veins, for example) and ultrasound Duplex scan (presence of venous reflux) (see related article).
Stage C3 is when edema is present permanently or very frequently throughout the day.
This edema often appears in the presence of old, untreated varicose veins, which have become more pronounced, leading to a significant disturbance in venous drainage.
Edema is favored by trampling, long journeys, lack of physical activity, heat, and peaks in female hormone secretion (estrogen and progesterone). It is therefore generally more marked at the end of the day and/or in summer.
Edema is often the cause of pain and discomfort, sometimes leading to actual pain (C3s stage), but sometimes it is completely symptom-free (C3a stage).
Wearing venous compression stockings limits the appearance of edema, as does physical activity.
Manual lymphatic drainage by a physiotherapist is indicated in the presence of associated lymphatic edema, which is quite frequent.

The onset of skin disorders represents the most advanced stage of venous disease.
These disorders generally appear after years of varicose vein disease, as they reflect a major disturbance in venous drainage, with permanent venous hyperpressure and chronic inflammation, which ultimately has deleterious effects on skin tissue.

Stage C4 is characterized by hypodermatitis or lipodermotosclerosis, ochre dermatitis or white atrophy. This is characterized by induration of the skin and subcutaneous tissue, which weakens these tissues and exposes them to wounds. This induration is associated with a permanent change in skin color, in the form of a brownish pigmentation (sometimes white due to depigmentation) that can become permanent.
Hypodermatitis can also be inflammatory, red, hot and painful.

Stage C6 is that of the ulcer, which generally appears within the hypodermitis, i.e. after stage C4. Venous ulcers often occur spontaneously or after minimal trauma, as the skin in the hypodermis zone is very fragile. Venous ulcers tend to worsen and spread, with frequent superinfection. Healing is very difficult, requiring repeated and complex dressings by specialized health professionals (doctors and nurses). Recurrence is frequent in the absence of treatment for the underlying venous pathology.

Stage C5 refers to the presence of an ulcer scar and, despite its lower numbering, comes after stage C6. This scar is indelible, so it remains a highly fragile zone, particularly in the absence of treatment for the original venous disease, which explains the frequent recurrence of the ulcer with the appearance of a new wound in the scarred zone.

The vast majority of C4, C5 and C6 stages are the result of varicose disease, but the consequences of deep phlebitis are the second most frequent venous cause.

Venous insufficiency skin disorders affect approximately 1% of the population in developed countries. They have a major impact on quality of life, with very high healthcare costs due to the length and complexity of the care required, hence the importance of preventing them by treating venous disease at an earlier stage.

Varicose veins are not only a cosmetic problem, they are also a primary cause of medical problems.
It is a progressive disease, with several stages of increasing severity.
The vast majority of patients present with venous insufficiency at the stage of uncomplicated varicose veins (C2), sometimes with oedema (C3), which can be treated by simple means, starting with the ASVAL method.
This should encourage patients to undergo early detection and treatment, so as to limit the progression of venous insufficiency, keeping it at a C1 or C2 stage and minimizing the spread of the disease in subsequent years.