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controls for all eight domains of the SF-36. Significance was achieved in four of eight
domains and in two of the eight domains for females and males respectively. Following
surgery for varicose veins patients’ quality of life improved in one domain (mental health)
six weeks post surgery (14). Another study found that at six months patients who had
undergone varicose vein surgery showed significant improvements in health scores using
both SF-36 and EuroQol scores (15).
Similarly, recurrent varicose veins at the time of re-presentation have a greater
negative influence on patients’ quality of life than primary disease when measured by
validated health-related quality of life and general quality of life tools (16).
CONCLUSION
Funding difficulties will be an ongoing issue in the management of venous diseases. It is
paramount that health economics continues to play a vital role in the delivery of health care
to patients with venous disorder, a subject some believe is a “Cinderella field of study.”
Quality of life should be a standard measure in future studies in patients with
venous disorders, preferably with a combination of generic and disease-specific measures.
There also needs to be longitudinal research on the long-term effect of chronic venous
disease on the quality of life of patients and its impact on the partners and
families concerned.
KEY POINTS
† The impact of venous disorders on health services is large both in terms of time
consumed and cost.
† There is no single quality of life tool that can be used to measure the impact of
venous disorders on patients.
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healing. BMJ 1992; 305:1389–1392.
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9. Michaels JA, Campbell WB, Brazier JE, et al. Randomised Trial of Treatment for Uncomp-
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32. Franks PJ, Moffatt CJ. Health related quality of life in patients with venous ulceration: use of
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6
Classification of Chronic Venous Disease
and Outcome Assessment
Gudmundur Danielsson and Bo Eklo
¨
f
Department of Vascular Diseases, Lund University, Lund, Sweden
INTRODUCTION
The field of chronic venous disorders (CVD) previously suffered from a lack of precision in
diagnosis. Thisdeficiency led to conflicting reportsin studies of the management of specific
venous problems at a time when new modalities werebeing offered to improve treatment for
simple, as well as more complicated, venous diseases. It was believed that these conflicts
could be resolved by a precise diagnosis and classification of the underlying venous
problem. The CEAP classification (1) (Clinical-Etiology-Anatomy-Pathophysiology) was
developed by an international consensus committee organized by the American Venous
Forum (AVF) in 1994 and adopted world-wide to facilitate meaningful communication
about CVD and to serve as a basis for a more scientific analysis of the management
alternatives. Thisclassification, based on a correct diagnosis, was also expected to serve asa
systematic guide in the daily clinical investigation of patients as an orderly documentation
system and basis for decisions regarding the appropriate treatment. It is important to stress
that CEAP is a descriptive classification and not a severity scoring system. A venous
severity scoring system was also developed in 1994 with an improvement presented by an
AVF committee on outcomes in 2000 (2). Together with patient-derived functional
assessments (Quality of Life, QoL scores), the venous severity scoring system are
instruments for longitudinal research to assess outcomes.
THE CREATION OF THE CEAP CLASSIFICATION
There have been several classifications of CVD in the past, the Widmer classification
being the most well known (3), but all lack the completeness and objectivity needed for
scientific accuracy (Table 1).
At the fifth annual meeting of the AVF in 1993, John Porter suggested using the same
approach as TNM for cancer in developing a classification system for venous diseases.
Following a year of intense discussions a consensus conference was held at the sixth annual
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meeting of AVF in February 1994, at which an international ad hoc committee, chaired
by Andrew Nicolaides, and with representatives from Australia, Europe, as well as the
Unites States, developed the first CEAP consensus document. It contained two parts,
a classification of CVD and a scoring system of the severity of CVD. The classification was
based on clinical manifestations (C), etiologic factors (E), anatomic distribution of disease
(A), and the underlying pathophysiological findings (P), thus the name CEAP. The severity
scoring system was based on three elements: the number of anatomic segments affected,
grading of symptoms and signs, and disability. The CEAP consensus statement was
published in 26 journals and books in nine languages (Table 2), truly a universal document
for CVD. It was endorsed by the Joint Councils of the Society for Vascular Surgery and the
North American Chapter of the International Society for Cardiovascular Surgery, and its
basic elements were incorporated into venous reporting standards (4). Today most
published clinical papers on CVD use all or portions of the CEAP classification.
OTHER DEVELOPMENTS RELATED TO CEAP
In 1998, at an international consensus meeting in Paris, Perrin et al. (5) established
a classification for recurrent varicose veins, REVAS, the evaluation of which is ongoing.
In 2000, Rutherford et al. (2)—the ad hoc committee of AVF on Outcomes—published an
upgraded version of the original venous severity scoring system. Carpentier, Cornu-Thenard
and Uhl established a European Venous Registry based on CEAP, and reported studies
on intra- and interobserver variability showing significant discrepancies in the clinical
classification of CEAP, prompting improved definitions of clinical classes C0 to C6 (6).
An international consensus meeting in Rome in 2001 suggested definitions and
refinements of the clinical classification, the “C” in CEAP (7). which were published
with a commentary by the first author of the current revision of the venous reporting
standards (8). These did not only contribute to CEAP, but formed the basis for its
ultimate modification, as recommended below.
REVISION OF CEAP
The diagnosis and treatment of CVD is developing rapidly and the need for an update of
the classification logically follows. It is important to stress that CEAP is a descriptive
Table 1 Published Classifications of Chronic Venous Disorders
Author Year
Widmer (3) 1978
Hach et al. (25) 1980
Partsch (26) 1980
Molokhia (27) 1981
Sytchev (28) 1985
Pierchalla and Tronnier (29) 1985
Porter et al. (30) 1988
Cornu-Thenard et al. (31) 1991
Enrici and Caldevilla (32) 1992
Miranda et al. (33) 1993
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classification. Venous Severity Scoring was developed to allow longitudinal outcome
assessment, but it became apparent that CEAP itself required updating and modification
(2). In April 2002, an ad hoc committee on CEAP was appointed by AVF to review
the classification and make recommendations for change by 2004, 10 years after its
introduction (Table 3). An international ad hoc committee was also established to assure
continued universal utilization (Table 4). The two held four joint meetings, with key
members contributing in the interim to the revised document. The revision of the CEAP
classification is published in the Journal of Vascular surgery (9).
Table 3 Members of the American Venous Forum Ad Hoc Committee on Revision of
CEAP Classification
John Bergan
Bo Eklof, Chair
Peter Gloviczki
Robert Kistner
Mark Meissner, Secretary
Gregory Moneta
Frank Padberg
Robert Rutherford
Thomas Wakefield
Table 2 Journals and Books in Which the CEAP Classification Has Been Published
Actualite
´
s Vasculaires Internationales 1995; 31:19–22
Angiologie 1995; 47:9–16
Angiology News 1996; 19:4–6
Australia and New Zealand Journal of Surgery 1995; 65:769–72
Clinica Terapeutica 1997; 148:521–6
Dermatologic Surgery 1995; 21:642–6
Elleniki Angiochirurgiki 1996; 5:12–9
European Journal of Vascular and Endovascular Surgery 1996; 12:487–91
Forum de Flebologia y Limphologia 1997; 2:67–74
Handbook of Venous Disorders 1996; 652–60
International Angiology 1995; 2:197–201
Japanese Journal of Phlebology 1995; 1:103–8
Journal of Cardiovascular Surgery 1997; 38:437–41
Journal of Vascular Surgery 1995; 21:635–45
Journal des Maladies Vasculaires 1995; 20:78–83
Mayo Clinic Proceedings 1996; 71:338–45
Minerva Cardioangiologica 1997; 45:31–6
Myakkangaku 1995; 31:1–6
Phle
´
bologie–Annales Vasculaires 1995; 48:275–81
Phlebologie (German version) 1995; 24:125–9
Phlebology 1995; 10:42–5
Przeglad Flebologiczny 1996; 4:63–73
Scope on Phlebology and Lymphology 1996; 3:4–7
VASA 1995; 24:313–8
Vascular Surgery 1996; 30:5–11
Vensjukdomar 2004; 89–91
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The following passages summarize the results of these deliberations, by describing
the new aspects of the revised CEAP.
The recommended changes, detailed below, include: additions to or refinements of
several definitions used in describing CVD; refinement of the C-classes of CEAP; addition
of the descriptor n (no venous abnormality identified); incorporation of the date of
classification and level of clinical investigation, and the description of basic CEAP,
introduced as a simpler alternative to the full (advanced) CEAP classification.
TERMINOLOGY AND NEW DEFINITIONS
The CEAP classification deals with all forms of CVD. The term chronic venous disorder
(CVD) includes the full spectrum of morphological and functional abnormalities of the
venous system from telangiectasies to venous ulcers. Some of these, like telangiectasies,
are highly prevalent in the normal adult population and in many cases the use of the
term “disease” is not appropriate. The term chronic venous insufficiency (CVI) implies
a functional abnormality of the venous system and it is usually reserved for patients with
more advanced diseases including those with edema (C3), skin changes (C4) or venous
ulcers (C5–6).
Table 4 The International Ad Hoc Committee on Revision of CEAP Classification
The AVF ad hoc committee plus
Claudio Allegra, Italy
Pier Luigi Antignani, Italy
Patrick Carpentier, France
a
Philip Coleridge Smith, UK
a
Andre
´
Cornu-Thenard, France
Ermenegildo Enrici, Argentina
Jean Jerome Guex, France
Shunichi Hoshino, Japan
Arkadiusz Jawien, Poland
Nicos Labropoulos, USA
Fedor Lurie, USA
Mark Malouf, Australia
Nick Morrison, USA
Kenneth Myers, Australia
a
Peter Negle
´
n, USA
Andrew Nicolaides, Cyprus
Tomo Ogawa, Japan
Hugo Partsch, Austria
Michel Perrin, France
a
Eberhard Rabe, Germany
Seshadri Raju, USA
Vaughan Ruckley, UK
a
Ulrich Schultz-Ehrenburg, Germany
Jean Francois Uhl, France
Martin Veller, South Africa
Yuqi Wang, China
Zhong Gao Wang, China
a
Editorial committee.
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It was agreed to maintain the present overall structure of the CEAP classification,
but to add more precise definitions. The following recommended definitions apply to the
clinical “C” classes in CEAP:
Telangiectasia a confluence of dilated intradermal venules of less than 1 mm in
caliber. Synonyms include spider veins, hyphen webs, and thread veins.
Reticular veins dilated bluish subdermal veins usually from 1 mm in diameter to
less than 3 mm in diameter. They are usually tortuous. This excludes normal
visible veins in people with thin, transparent skin. Synonyms include blue
veins, subdermal varices, and venulectasies.
Varicose veins subcutaneous dilated veins equal to or more than 3 mm in diameter
measuredin the uprightposition. Thesemay involve saphenous veins,saphenous
tributaries, or non-saphenous superficial leg veins. Varicose veins are usually
tortuous, but tubular saphenous veins with demonstrated reflux may be classified
as varicose veins. Synonyms include varix, varices, and varicosities.
Corona phlebectatica a fan-shaped pattern of numerous small intradermal veins on
the medial or lateral aspects of the ankle and foot. This is commonly thought to
be an early sign of advanced venous disease. Synonyms include malleolar flare
and ankle flare.
Edema a perceptible increase in the volume of fluid in the skin and subcutaneous
tissue, characteristically indented with pressure. Venous edema usually occurs
in the ankle region, but it may extend to the leg and foot.
Pigmentation a brownish darkening of the skin resulting from extravasated blood,
which usually occurs in the ankle region, but may extend to the leg and foot.
Eczema an erythematous dermatitis, which may progress to a blistering, weeping,
or scaling eruption of the skin of the leg. It is most often located near varicose
veins, but may be located anywhere in the leg. Eczema is usually seen in
uncontrolled CVD but may reflect sensitization to local therapy.
Lipodermatosclerosis (LDS) localized chronic inflammation and fibrosis of the
skin and subcutaneous tissues of the lower leg, sometimes associated with
scarring or contracture of the achilles tendon. LDS is sometimes preceded by
diffuse inflammatory edema of the skin, which may be painful and which is
often referred to as hypodermitis. This condition must be distinguished from
lymphangitis, erysipelas or cellulitis by their characteristically different local
signs and systemic features. LDS is a sign of severe CVD.
Atrophie blanche or white atrophy localized, often circular whitish and atrophic
skin areas surrounded by dilated capillaries and sometimes hyperpigmenta-
tion. This finding is a sign of severe CVD and not to be confused with
healed ulcer scars. Scars of healed ulceration may also have atrophic skin
with pigmentary changes, but are distinguishable by the history of ulceration
and appearance from atrophie blanche and are excluded from this definition.
Venous ulcer full thickness defect of the skin most frequently in the ankle region
that fails to heal spontaneously and is sustained by CVD.
REFINEMENT OF C-CLASSES IN CEAP
The essential change here is the division of class C4 into two subgroups, which reflect
different severities of disease, and carry a different prognosis in terms of risk of ulceration:
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C0 no visible or palpable signs of venous disease.
C1 telangiectasies or reticular veins.
C2 varicose veins—distinguished from reticular veins by a diameter of 3 mm
or more.
C3 edema.
C4 changes in the skin and subcutaneous tissue secondary to CVD (now divided
into two subclasses to better define the differing severity of venous disease):
C4a pigmentation and/or eczema;
C4b LDS and/or atrophie blanche.
C5 healed venous ulcer.
C6 active venous ulcer
Each clinical class is further characterized by a subscript for the presence of
symptoms (S, symptomatic) or absence of symptoms (A, asymptomatic), e.g., C2
A
,orC5
S
.
The symptoms include aching, pain, tightness, skin irritation, heaviness, and muscle
cramps, as well as other complaints attributable to venous dysfunction.
REFINEMENT OF E, A, AND P IN CEAP
To improve the assignment of designations under the E, A, and P a new descriptor n is now
recommended for use where no venous abnormality is identified. This n could be added to
E (En: no venous etiology identified), A (An: no venous location identified) and P (Pn: no
venous pathophysiology identified). Observer variability in assigning designations may
have been contributed to by the lack of a normal option. Further definition of the A and P
has also been afforded by the new venous severity scoring system (2), which was
developed by the ad hoc Committee on Outcomes of the AVF to compliment CEAP.
It includes not only a Clinical Severity Score, but also a Venous Segmental Score. The
latter is based on imaging studies of the leg veins, e.g., duplex scan, and the degree of
obstruction or reflux (P) in each major segment (A) and forms the basis for the overall
score (see further below).
This same committee is also pursuing a prospective multicenter investigation of the
variability in vascular diagnostic laboratory assessment of venous hemodynamics in
patients with CVD. The last revision of the venous reporting standards still cites changes
in ambulatory venous pressure or plethysmographically measured venous return time
(VRT) as objective measures of change (4). The current multicenter study aims to
establish the variability, and thus the limits, of “normal” for the VRT and the newer non-
invasive venous tests as an objective basis for claiming significant improvement as a result
of therapy, and it will hopefully provide improved reporting standards for definitive
diagnosis and results of competitive treatments in patients with CVD.
DATE OF CLASSIFICATION
CEAP is not a static classification; the patient can be reclassified at any future point in
time. The classification starts with the initial visit, but can be better defined after further
investigations. A final classification may not be complete until after surgery and
histopathologic assessment. We therefore recommend that any CEAP classification be
followed by the date, e.g., C4b, S, Ep, As, p, Pr (2003-08-21).
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LEVEL OF INVESTIGATION
A precise diagnosis is the basis of correct classification of the venous problem. The
diagnostic evaluation of the patient with CVD can be logically organized into one or more
of three levels of testing, depending on the severity of the disease:
Level I the office visit with history and clinical examination, which may include
the use of a hand-held Doppler.
Level II the noninvasive vascular laboratory, which now routinely includes
duplex color scanning, with some plethysmographic method added as desired.
Level III invasive investigations or more complex imaging studies including
ascending and descending venography, venous pressure measurements, CT
scan, venous helical scan or MRI.
We recommend that the level of investigation (L) should also be added to the
classification, e.g., C2, 4b, S, Ep, As, p, Pr (2003-08-21,L II).
BASIC CEAP
A new basic CEAP is offered here. Use of all components of CEAP is still encouraged.
Unfortunately, many use the C-classification only, which is only a modest advance beyond
the previous classifications based solely on the clinical appearance. Venous disease is
complex, but can be described by the use of well-defined categorical descriptions. For the
practicing physician, CEAP can be a valuable instrument for correct diagnosis to guide
treatment and assess prognosis. In modern phlebological practice the vast majority of
patients will have a duplex scan of the venous system of the leg, which will largely define
the E, A, and P categories.
Nevertheless, it is recognized that the merits of using the full (advanced) CEAP
classification system hold primarily for the researcher and for standardized reporting in
scientific journals. It allows grouping of patients so that the same types of patients can be
analyzed together and such a subgroup analysis allows their treatments to be more
accurately assessed. Furthermore, reports using CEAP can be compared with one another
with much greater certainty. This more complex classification, for example, also allows
any of the 18 named venous segments to be identified as the location of venous pathology.
Take a patient with pain, varicose veins and LDS, where duplex scan confirms primary
reflux of the great saphenous vein and incompetent perforators in the calf. The
classification here would be C2, 4b, S, Ep, As, p, Pr2, 3, 18.
While the detailed elaboration of venous disease in this form may seem
unnecessarily complex, even intimidating, to some clinicians, it provides universal
understandable descriptions, which may be essential to the investigators in the field. To
serve the needs of both, the full CEAP classification, as modified above, is retained as
advanced CEAP and the following simplified form is offered as basic CEAP.
In essence, basic CEAP applies two simplifications:
1. In basic CEAP the single highest descriptor can be used for clinical
classification. For example, a patient with varicose veins, swelling and LDS
would be C4b. The more comprehensive clinical description, in advanced
CEAP, would be C2, 3, 4b
2. In basic CEAP, where duplex scan is performed, E, A, and P should also be
classified by using the multiple descriptors recommended, but the complexity of
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