What is the CEAP (Clinical, Etiological, Anatomical, Pathophysiological) classification system and how is it used to diagnose and treat chronic venous disorders?

CEAP Classification for Chronic Venous Disorders

What CEAP Is and Its Core Components

The CEAP classification is a standardized international system that categorizes chronic venous disorders using four components: Clinical manifestations (C0-C6), Etiological factors (congenital, primary, or secondary), Anatomical distribution (superficial, deep, or perforator veins), and Pathophysiological mechanisms (reflux, obstruction, or both). 1, 2

The classification provides standardized terminology for describing venous disease severity, enabling comparison of treatment outcomes across different studies and facilitating communication between healthcare providers. 1

Clinical Classification (C0-C6)

The clinical component uses seven classes based on objective clinical signs: 3, 2

• C0: No visible or palpable signs of venous disease
• C1: Telangiectasias or reticular veins
• C2: Varicose veins (>3mm diameter in standing position), with C2R designating recurrent varicose veins 2, 4
• C3: Edema of venous origin
• C4: Skin changes, subdivided into:
  • C4a: Pigmentation or eczema 2, 4
  • C4b: Lipodermatosclerosis or atrophie blanche 2, 4
  • C4c: Corona phlebectatica (ankle flare) - added in 2020 update 2, 4
• C5: Healed venous ulcer
• C6: Active venous ulcer, with C6R designating recurrent active ulcer 2, 4

Etiological Classification

The etiology component identifies the cause: 4

• EC: Congenital venous disorders
• EP: Primary venous disease (no identifiable cause)
• ES: Secondary venous disease, further subdivided into:
  • ESI: Intravenous secondary causes (venous wall/valve damage from post-thrombotic syndrome, trauma) 4
  • ESE: Extravenous secondary causes (no venous damage but altered hemodynamics from pregnancy, obesity, arteriovenous fistula) 4
• EN: No cause identified (diagnosis of exclusion when symptoms exist but no other etiology found) 4

Anatomical Classification

The anatomical component uses abbreviations instead of numbers to identify affected venous segments, including superficial veins (great saphenous vein, small saphenous vein, tributaries), deep veins (femoral, popliteal, tibial), and perforator veins. 2, 4 This allows precise documentation of which venous segments are involved. 5

Pathophysiological Classification

The pathophysiology component identifies the mechanism: 3, 4

• PR: Reflux (backward flow due to valve incompetence)
• PO: Obstruction (blockage of venous outflow)
• PR,O: Both reflux and obstruction present
• PN: No venous pathophysiology identified

Clinical Applications and Treatment Guidance

The CEAP classification guides appropriate treatment selection based on disease classification. 1 For example, patients with C4c disease (corona phlebectatica) are considered to have moderate-to-severe venous insufficiency and may benefit from intervention. 6

The classification describes disease but does not quantify severity or functional impairment, which is a critical limitation. 1 It has limited ability to monitor changes over time and does not incorporate assessment of symptom severity. 3, 1

Important Limitations and When to Use Alternative Scoring Systems

For longitudinal assessment and treatment monitoring, the Venous Clinical Severity Score (VCSS) or Villalta scale should be used instead of CEAP alone. 1 The VCSS combines CEAP elements with additional criteria such as compression therapy use and ulcer characteristics, allowing assessment of change with treatment. 3

The Villalta scale is specifically developed for post-thrombotic syndrome diagnosis and monitoring, showing good correlation with quality of life scores and anatomic markers. 3

Common Pitfalls to Avoid

• CEAP is not a severity scoring system - it categorizes disease but doesn't measure how severe symptoms are or how much they impact function 1, 7
• C2 summarizes all types of varicose veins without distinguishing between minor cosmetic concerns and extensive symptomatic disease 7
• C3 edema may be difficult to attribute solely to venous causes versus other etiologies like lymphatic or cardiac disease 7
• The classification requires objective testing (duplex ultrasound, plethysmography) to accurately determine etiology, anatomy, and pathophysiology - clinical examination alone is insufficient 5

Evidence Quality and Updates

The CEAP classification was originally developed in 1994, revised in 2004, and most recently updated in 2020 by the American Venous Forum. 2, 8 The 2020 update added corona phlebectatica as C4c, introduced the "r" modifier for recurrent disease, and replaced numeric venous segment descriptions with abbreviations to improve clarity. 2, 4