CEAP Classification for Chronic Venous Disorders
What CEAP Is and Its Primary Purpose
The CEAP classification is an internationally accepted standardized system for describing and categorizing chronic venous disorders based on Clinical manifestations, Etiological factors, Anatomical distribution, and Pathophysiological mechanisms. 1, 2
The classification serves three essential functions according to major medical societies:
- Standardizes terminology for describing venous disease severity, enabling comparison of treatment outcomes across different studies and facilitating communication between healthcare providers 1
- Guides treatment selection based on disease classification, helping clinicians determine appropriate interventions 1
- Enables research standardization by providing consistent reporting criteria in clinical studies 3, 2
The Four Components of CEAP
Clinical Classification (C0-C6)
The clinical component categorizes visible and symptomatic manifestations 3, 2:
- C0: No visible or palpable signs of venous disease 2
- C1: Telangiectasies or reticular veins 2
- C2: Varicose veins (>3mm diameter in standing position) 3, 2
- C3: Edema 2
- C4: Skin changes (subdivided into three categories in 2020 update) 2, 4
- C5: Healed venous ulcer 2
- C6: Active venous ulcer 2
Etiological Classification (E)
This component identifies the origin of venous disease 4, 5:
- EC: Congenital 4, 5
- EP: Primary (no identifiable cause) 4, 5
- ES: Secondary (post-thrombotic, post-traumatic, or other known cause) 4, 5
- EN: No cause identified (diagnosis of exclusion when symptoms exist but no other etiology found) 4
Anatomical Classification (A)
The 2020 update replaced numeric descriptions with anatomical abbreviations for venous segments 1, 2, 4:
- Superficial veins (S): Great saphenous vein (GSV), small saphenous vein (SSV), tributary veins 1, 4
- Deep veins (D): Inferior vena cava, common femoral, femoral, popliteal, tibial veins 1, 4
- Perforating veins (P): Thigh, calf perforators 1, 4
Pathophysiological Classification (P)
This describes the underlying hemodynamic abnormality 1, 4:
- PR: Reflux 1, 4
- PO: Obstruction 1, 4
- PR,O: Both reflux and obstruction 1, 4
- PN: No venous pathophysiology identified 4, 5
Critical Limitations Clinicians Must Understand
The American Heart Association explicitly states that CEAP has limited ability to monitor change over time and does not incorporate assessment of symptom severity, making it not ideal for diagnosing and following post-thrombotic syndrome. 3
Additional limitations include:
- Not a severity scoring system - CEAP describes disease but does not quantify severity or functional impairment 3, 6
- C2 encompasses all varicose veins regardless of size or extent, limiting discrimination within this category 6
- C3 edema classification may be difficult to attribute solely to venous causes versus other etiologies 6
- Most publications use only the clinical (C) component, not the full classification system 6
When to Use CEAP vs. Alternative Scoring Systems
For longitudinal assessment and treatment monitoring, use the Venous Clinical Severity Score (VCSS) or Villalta scale instead of CEAP. 3
- CEAP: Best for initial categorization, research standardization, and communication between providers 1, 2
- VCSS: Combines CEAP elements with additional criteria (compression use, ulcer number/duration) allowing assessment of change with treatment 3
- Villalta scale: Specifically developed for post-thrombotic syndrome diagnosis and monitoring 3
Practical Application in Clinical Practice
The 2020 update introduced a basic CEAP version as a simpler alternative to the full (advanced) classification for routine clinical use 5. The basic version focuses on clinical classification with simplified anatomical and pathophysiological descriptors 5.
Documentation should specify the date of classification and level of investigation (clinical examination alone vs. with duplex ultrasound vs. with advanced imaging) to ensure reproducibility 5, 7.