Clinical class
Description
C0
No visible or palpable signs of venous disease
C1
Telangiectases or reticular veins
C2
Varicose veins
C3
Edema
C4
Changes in the skin and subcutaneous tissue
C4a Pigmentation and/or eczema
C4b Lipodermatosclerosis and/or atrophie blanche
C5
Healed venous ulcer
C6
Active venous ulcer
CEAP: Etiological Classification [1, 2]
Three causes are identified under etiological classification:
Congenital – refers to conditions where the vessels are deformed from birth as, for example, Klippel-Trenaunay syndrome.
Primary – refers to degenerative conditions of the vein wall with reflux as in varicose veins.
Secondary – commonest cause is post-thrombotic syndrome.
The revised CEAP has included a fourth group, “No venous etiology identified” with the superscript “n” (Table 4.2).
Table 4.2
Etiological classification
E c | Congenital |
E p | Primary |
E s | Secondary (post-thrombotic) |
E n | No venous etiology identified |
CEAP: Anatomical Classification [1, 2]
This has primarily three components based on the location of the disease: superficial veins (s), perforator veins (p), and deep vein (d). The revised document has incorporated a fourth category, “n”, when no venous location could be identified (Table 4.3).
Table 4.3
Anatomical classification
A s | Superficial veins |
A p | Perforating veins |
A d | Deep veins |
A n | No venous location identified |
When an abnormality is identified, to further localize the disease, 18 venous segments from the infradiaphragmatic IVC to the crural veins are recognized (refer later).
CEAP: Pathophysiological Classification [1, 2]
The basic changes here are reflux(r), obstruction (o), and combination of both reflux and obstruction (r,o). The descriptor “n” is employed when no pathology could be identified (Table 4.4).
Table 4.4
Pathophysiological classification
P r | Reflux |
P o | Obstruction |
P r,o | Reflux and obstruction |
P n | No venous pathology identifiable |
When reflux or obstruction is detected, further anatomical localization of the pathophysiology can be done by considering venous anatomical segment classification [2] (Table 4.5).
Table 4.5
Venous anatomical segment classification
Superficial veins |
1. Telangiectases/reticular veins |
2. GSV above knee |
3. GSV below knee |
4. SSV |
5. Nonsaphenous veins |
Deep veins |
6. Inferior vena cava |
7. Common Iliac vein |
8. Internal iliac vein |
9. External iliac vein |
10. Pelvic: gonadal, broad ligament veins, etc. |
11. Common femoral vein |
12. Deep femoral vein |
13. Femoral vein |
14. Popliteal vein |
15. Crural veins: anterior tibial, posterior tibial, peroneal veins |
16. Muscular veins: gastrocnemius, soleus, etc. |
Perforating veins |
17. Thigh perforating veins |
18. Calf perforating veins |
CVD are progressive and not static problems. Serial CEAP classification is necessary to understand the progression of the disease. The revised document has suggested inclusion of the date of CEAP classification and the level of investigation to make it more dynamic [1]. Three levels of investigations are recognized.
Level I Investigation – office visit with history and clinical examination; includes use of handheld Doppler (HHD)
Level II Investigations – noninvasive studies (duplex color scanning along with some form of plethysmographic studies if needed)
Level III Investigations – invasive studies (Ascending/descending venogram, ambulatory venous pressure studies, CT/MR venograms)
Full/Advanced CEAP and Basic CEAP
It is essential that the CEAP classification should be simple enough for routine clinical use. At the same time, it should be comprehensive for research and publication purposes. To achieve these twin goals, the revision committee has recommended a basic CEAP and an advanced/full CEAP classification.
For basic CEAP, two simplifications are suggested [1]:
The single highest descriptor can be used for clinical classification.
After duplex scan, in basic CEAP, the E, A, and P factors are also to be documented. But the complex 18 venous anatomical segment classification can be avoided.
For advanced CEAP classification, the full spectrum is to be used [1].
The clinical classification should include the full range of descriptors (see example below).
Venous anatomical segments are also to be included.
The following example would clarify the issue.
A patient has varicose veins with pain and lipodermatosclerosis. Duplex scan on 02/02/2014 confirmed primary reflux of GSV and incompetent perforators in the calf.
The basic CEAP of this patient would be C4b s; E p; A s p; P r; Level II; 02/02/2014.
The advanced CEAP for this patient would be C2,3,4b s; Ep; A s p; P r 2,3,18; Level II; 02/02/2014.
The advanced CEAP looks a little intimidating, but it is relevant for standardization and cohort study. The revision of the CEAP is an ongoing program of the American Venous Forum and further modifications are likely to emerge.
Outcome Assessment
Venous Severity Scoring (VSS) Systems: Problems and Issues
Any system aimed at evaluating the severity of disease and outcome of therapy should contain objective and quantifiable elements. Further, these elements should reflect positive or negative impact to specific interventions and treatments. Venous diseases, unlike peripheral arterial diseases, do not have well-defined measurable end points. Again, there is no noninvasive test on the venous side, which will provide a quantifiable data on the outcome of therapy. On the arterial side, the ankle brachial pressure index is a very simple noninvasive test, which has all the required criteria for outcome measurement. These issues make severity scoring and outcome assessment more complicated on the venous system [3]. The CEAP is an excellent system for classifying CVD. But when it comes to using CEAP for severity and outcome assessment, problems arise. The CEAP in its current form is basically a static system. For example, in C4 lesions, lipodermatosclerosis is unlikely to change with treatment [4]. An ad hoc committee of the American Venous Forum, under the leadership of Dr. Rutherford, arrived at three severity scoring systems based on the elements of the CEAP [4]. The “E” component of the CEAP was not incorporated since it is a fixed entity [3]. The scoring systems evolved are [4] as follows:
Venous Clinical Severity Score (VCSS) – basically derived from the clinical classification of CEAP.
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