CEAP Classification of Varicose Veins​

C2: Varicose Veins

Varicose veins usually bulge out when the patient stands up and then disappear when the patient lies down or raises their legs. 

What You Can See in Varicose Veins

Usually noticed in the calf and lower leg, the varicose veins’ bulges on the legs can extend everywhere from the buttocks and groin areas to the feet. Also, if you notice discolored patches around the ankles, it indicates CEAP C4 skin damage. Also, when the varicose veins are relatively deep, the skin overlying the vein bulges too, and the dark colored blood is not visible through the skin. In such a case, the bulges are colored. 

The deoxygenated blood in the veins is visible through the skin if the veins are near the surface of the skin. These bulging varicose veins look green or bluish purple. The color and the bulge disappear when the legs are elevated and the blood flows out of the varicose veins.  

The bulges’ distribution helps the doctors understand where the veins are coming from. If the bulges are around the top of the thighs, buttocks, perineal area, or near the vulva and vagina in women or the top of the scrotum in men, then it certainly indicates that the varicose veins are arising from pelvic vein reflux.  

In such patients, proper diagnosis of the pelvic veins is essential to begin the treatment 

Cause of Varicose Veins

In the majority of cases, the failure of vein valves is the primary cause of varicose veins in the legs (and pelvis). Veins must pump blood against gravity in order to return it to the heart. The blood inside the veins is forced upward by the movement of the leg muscles. In the majority of people, valves seal to stop blood from returning to the veins. 

In people who suffer from varicose veins, these valves give way and allow blood to flow back down the veins. This is called venous reflux. The skin surrounding the ankle and lower leg may sustain injury as a result of the blood returning to the veins. To prevent this from occurring, the body produces “shock absorbers” to divert the descending blood away from the ankle veins. The dilated veins that serve as “shock absorbers” are the varicose veins.

When standing, varicose veins become stiff and protrude because the blood falls back down the veins due to gravity. Likewise, when the legs are raised, the varicose veins disappear and the blood gravitationally returns to the heart through the veins.

Varicose veins in the legs are also caused by the obstructions of the pelvic veins, such as pelvic tumors, pregnancy, constipation, obesity, and other conditions that increase abdominal pressure. If blockages of the pelvic veins are the cause of varicose veins, the veins would not only swell when standing but would also continue to swell when lying down, since the blood would not be able to flow out of the leg.

Diagnosis of Varicose Veins

A duplex ultrasound scan will help you understand the underlying venous cause. The venous ultrasound scan examines every vein in the body in order to determine which veins in the legs are functioning normally and which are not. To ensure that there are no deep vein issues, such as an old deep vein thrombosis or deep venous reflux, this should encompass all of the superficial veins, the truncal veins, the perforator veins in the lower and upper legs, and all of the deep veins.

If there are any varicose veins surrounding the buttocks, perineum, vulva, or vagina in women, or the scrotum in men, further examination of the pelvic veins is necessary to determine whether varicose veins are originating from the pelvis.

Additionally, another test called a photoplethysmography (PPG) can also be done to examine how severe any venous reflux is.

• C2A: Varicose veins without symptoms

Varicose veins at this stage usually do not cause any symptoms. When standing, you may notice bulging varicose veins on the legs, which can be skin colored, blue, or green. While lying down, or elevating the leg, these reduce in size and sometimes even disappear. A venous duplex ultrasound scan is usually done in order to identify the risk associated and understand further deterioration. 

• C2S: Varicose veins with symptoms

Pain, aching, discomfort, heaviness, and itching are a few of the common symptoms experienced by patients in this stage. The underlying cause of symptomatic varicose veins is venous reflux.

C3: Swollen Ankles With Varicose Veins

Any sort of valve dysfunction, or when they stop working, causes the development of varicose veins. 

Another important classification after varicose veins is swollen ankles(sometimes also known as edema). 

When there are no visible varicose veins, but you notice swelling of the ankles(ankle edema) and there is venous reflux upon undergoing the duplex ultrasound scan, it is classified as the C3 classification of varicose veins. At this stage, you may also notice physical damage due to the inflammation caused by the varicose veins and venous reflux. 

Venous edema or swelling of the ankles caused by varicose veins affects the leg below the calf and around the ankle bones. Only sometimes it extends onto the foot and does not extend to the toes. If the swelling is too much, it could indicate lymphoedema or other generalised edema and not venous edema. 

Usually, in the morning, venous edema is rarely noticeable. However, after waking up, it starts to form. The severity of the varicose veins or hidden varicose veins, how active you are, and other factors are a few of the criteria that determine the speed at which the venous edema begins developing as the day progresses.  

Causes

When the blood flows down the veins, it hits the vein in the ankle, causing inflammation. One of the major consequences of inflammation is swelling. The ankle at this stage is hot, red, swollen, and painful.

Diagnosis

A venous duplex ultrasound scan is done in order to identify if the swelling is due to venous reflux. Additionally, a detailed examination of the swelling is also essential to identify if the swelling is due to obstruction or partial obstruction of the deep veins rather than just reflux. Several patients have experienced symptomatic relief after wearing the compression stockings.

C4: Skin Damage Due to Varicose Veins

When the blood falls down the veins of the legs due to valve malfunction, it causes inflammation in the lower legs and a rapid increase in pressure on standing. Gradually, it damages the surrounding tissues of the veins, too. In the earlier C3 stage, it is referred to as the collection of fluid, or edema. 

But when the damage gets worse, the inflammation spreads through the tissue under the skin, affecting the ankle skin. There can be redness, a brown area that is both itchy and red, and a shiny, tight, and hard patch in the damaged skin. The harder shiny patches, which are often discolored, are known as lipodermatosclerosis (or LDS), and the dark brown patches are known as haemosiderin deposition.

Skin damage due to varicose veins

The skin damage at this stage is usually noticed on the inner part of the lower leg, often above the ankle bone and below the calf muscle. Sometimes it is also seen around, under, and just behind the ankle bone. 

C5: Healed Venous Leg Ulcer

The symptoms at this stage are usually those of a healed venous leg ulcer. The important point to note here is that the CEAP classification is merely a clinical grade and not the progression from stage C1 to C6, as you can’t be experiencing the symptoms of a healed venous leg ulcer unless you have an active venous leg ulcer-CEAP C6. 

A healed venous leg ulcer represents the skin damage around the ankle or lower leg , which is usually experienced in CEAP C4. Also, there are high probabilities of healed venous leg ulcers coming back again if the underlying vein problem is not treated. Compression treatments at this stage are not usually long-term and may only heal the condition temporarily. 

Causes

The significant cause behind healed venous leg ulcers is usually  venous reflux, varicose veins, or hidden veins. Sometimes, it can be due to deep vein problems, too, such as deep vein reflux, recurrent deep vein thrombosis, or narrowing or blockage of the veins in the upper leg or pelvis, preventing the blood flow out of the leg veins efficiently. 

A venous duplex ultrasound needs to be done for the proper diagnosis. Your doctor may suggest an endovenous surgery to ensure that the ulcer is healed completely and will not come back again. 

C6: Active Venous Leg Ulcer

Leg ulcers are open wounds or non-healing skin sores, mainly caused by venous insufficiency and sometimes arterial problems, such as diabetes, pressure, vasculitis, and malignancy. The best part is that in the majority of cases, the underlying vein problem can be fixed, making the condition treatable. 

• Temporary healing:- Compression bandaging and dressing are used, which may cause the recurrence of the ulcer in the future. 
• Permanent healing:- It works on the underlying cause and prevents the recurrence. 

What You See in a Venous Leg Ulcer

Usually, the venous leg ulcer is experienced in the lower leg, just above the ankle bone. However, sometimes these can be around the leg and may spread from above the ankle bone to below the ankle bone. Rarely, they can occur at the back of the lower leg. Sometimes these can be very small and appear in just one place.

The ulcer appears to be an open sore, and can appear pink and healthy, or can have yellow-green debris within it, depending on how clean the ulcer is. The area surrounding the ulcer is usually red. The usual progression of venous disease is red and brown colored skin damage around the lower leg, which can progress to C6 if not treated. 

Treatment of a Venous Leg Ulcer

In most of the patients, the major cause behind developing leg ulcers has been the malfunctioning of the veins in the legs and pelvis. It can be treated using the modern endovenous procedures under local anesthesia after a diagnosis by venous duplex ultrasonography.  

Table for CEAP Classification of Varicose Veins​