What is the CEAP (Clinical, Etiological, Anatomical, and Pathophysiological) classification?

CEAP Classification for Chronic Venous Disorders

The CEAP classification is a standardized system that categorizes venous disease according to Clinical, Etiological, Anatomical, and Pathophysiological attributes, providing a comprehensive framework for diagnosing and comparing treatment outcomes in patients with chronic venous disorders. The CEAP classification is essential for accurately characterizing venous disease severity, guiding treatment decisions, and standardizing reporting in clinical research. 1

Clinical Classification (C)

• C0: No visible or palpable signs of venous disease 1, 2
• C1: Telangiectasias, reticular veins, malleolar flares 2
• C2: Varicose veins (≥3 mm in diameter) 1, 2
• C3: Edema of venous origin 1, 2
• C4: Skin changes attributed to venous disease:
  • C4a: Pigmentation or eczema 3
  • C4b: Lipodermatosclerosis or atrophie blanche 3
  • C4c: Corona phlebectatica (added in the 2020 update) 4, 3
• C5: Healed venous ulcer 1, 2
• C6: Active venous ulcer 1, 2

Etiological Classification (E)

• Ec: Congenital venous disorders 3, 2
• Ep: Primary venous disorders with undetermined cause 3, 2
• Es: Secondary venous disorders with known cause:
  • ESI: Intravenous causes (damage to venous wall/valves) 3
  • ESE: Extravenous causes (no direct damage to veins but affecting hemodynamics) 3
• En: No venous cause identified 3

Anatomical Classification (A)

The 2020 update replaced numeric descriptions with common abbreviations for venous segments 4, 3:

• Superficial veins (S): GSV (great saphenous vein), SSV (small saphenous vein), etc.
• Deep veins (D): IVC (inferior vena cava), CFV (common femoral vein), etc.
• Perforating veins (P): Thigh, calf, etc.

Pathophysiological Classification (P)

• PR: Reflux 1, 3
• PO: Obstruction 1, 3
• PR,O: Reflux and obstruction 1, 3
• PN: No venous pathophysiology identified 3

2020 Updates to CEAP Classification

• Addition of Corona phlebectatica as C4c clinical subclass 4, 3
• Introduction of modifier "r" for recurrent varicose veins (C2r) and recurrent venous ulcers (C6r) 4, 3
• Replacement of numeric descriptions of venous segments with common abbreviations 4, 3
• Further subcategorization of secondary causes (Es) into intravenous (ESI) and extravenous (ESE) 3

Clinical Application and Limitations

• CEAP is primarily a descriptive classification system, not a severity scoring system 5
• It has limited ability to monitor changes over time 1
• It does not incorporate assessment of symptom severity 1
• For comprehensive assessment, CEAP should be complemented with venous severity scoring and quality of life measures 5
• The classification should include the date of assessment and level of investigation 5

Importance in Clinical Practice

• Provides standardized terminology for describing venous disorders 1, 4
• Enables comparison of treatment outcomes across different studies 1, 6
• Facilitates communication between healthcare providers 4, 5
• Guides appropriate treatment selection based on disease classification 1
• Helps in monitoring disease progression over time, though with limitations 1, 6

Common Pitfalls and Caveats

• CEAP is not an ideal scoring system to diagnose and follow up the course of post-thrombotic syndrome (PTS) 1
• C2 summarizes all kinds of varicose veins without distinguishing severity 6
• In C3, it may be difficult to separate venous and other causes of edema 6
• The classification should be updated periodically as patients' conditions change 5
• For research purposes, the advanced CEAP with all components should be used, while basic CEAP may be sufficient for routine clinical practice 5