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Doi:10.1016/j.jvs.2004.09.027

SPECIAL COMMUNICATION
From the American Venous Forum
Revision of the CEAP classification for chronicvenous disorders: Consensus statement Bo Eklöf, MD,a Robert B. Rutherford, MD,b John J. Bergan, MD,c Patrick H. Carpentier, MD,d Peter
Gloviczki, MD,e Robert L. Kistner, MD,f Mark H. Meissner, MD,g Gregory L. Moneta, MD,h Kenneth
Myers, MD,i Frank T. Padberg, MD,j Michel Perrin, MD,k C. Vaughan Ruckley, MD,l Philip Coleridge
Smith, MD,m
and Thomas W. Wakefield, MD,n for the American Venous Forum International Ad Hoc
Committee for Revision of the CEAP Classification,
Helsingborg, Sweden
The CEAP classification for chronic venous disorders (CVD) was developed in 1994 by an international ad hoc committee
of the American Venous Forum, endorsed by the Society for Vascular Surgery, and incorporated into “Reporting
Standards in Venous Disease” in 1995. Today most published clinical papers on CVD use all or portions of CEAP.

Rather than have it stand as a static classification system, an ad hoc committee of the American Venous Forum, working
with an international liaison committee, has recommended a number of practical changes, detailed in this consensus
report. These include refinement of several definitions used in describing CVD; refinement of the C classes of CEAP;
addition of the descriptor n (no venous abnormality identified); elaboration of the date of classification and level of
investigation; and as a simpler alternative to the full (advanced) CEAP classification, introduction of a basic CEAP
version. It is important to stress that CEAP is a descriptive classification, whereas venous severity scoring and quality of
life scores are instruments for longitudinal research to assess outcomes. ( J Vasc Surg 2004;40:1248-52.)

The field of chronic venous disorders (CVD) previously agement alternatives. This classification, based on correct di- suffered from lack of precision in diagnosis. This deficiency led agnosis, was also expected to serve as a systematic guide in the to conflicting reports in studies of management of specific daily clinical investigation of patients as an orderly documen- venous problems, at a time when new methods were being tation system and basis for decisions regarding appropriate offered to improve treatment for both simple and more com- plicated venous diseases. It was believed that these conflictscould be resolved with precise diagnosis and classification of CREATION OF CEAP CLASSIFICATION
At the Fifth Annual meeting of the American Venous (Clinical-Etiology-Anatomy-Pathophysiology) was adopted Forum (AVF), in 1993, John Porter suggested using the worldwide to facilitate meaningful communication about same approach as the TNM classification (Tumor/Node/ CVD and serve as a basis for more scientific analysis of man- Metastasis) for cancer in developing a classification systemfor venous diseases. After a year of intense discussions a From the University of Lund,a Sweden, University of Colorado,b Denver, University of California San Diego,c University of Grenoble,d France, consensus conference was held at the Sixth Annual Meeting Mayo Clinic,e Rochester, Minn, University of Hawaii,f Honolulu, Uni- of AVF in February 1994, at which an international ad hoc versity of Washington,g Seattle, Oregon Health Science Center Universi- committee, chaired by Andrew Nicolaides and with repre- ty,h Portland, University of Melbourne,i Australia, University of Medicine sentatives from Australia, Europe, and the United States, and Dentistry of New Jersey,j Newark, University of Lyon,k France, developed the first CEAP consensus document. It con- University of Edinburgh,l United Kingdom, University College LondonMedical School,m United Kingdom, and University of Michigan,n Ann tained 2 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 Presented at the Sixteenth Annual Meeting of the American Venous Forum, distribution of disease (A), and underlying pathophysio- Additional material for this article may be found online at logic findings (P), or CEAP. The severity scoring system was based on 3 elements: number of anatomic segments Reprint requests: Bo Eklöf, MD, PhD, Batteritorget 8, SE-25270 Helsingborg, affected, grading of symptoms and signs, and disability.
The CEAP consensus statement was published in 25 jour- nals and books, in 8 languages online only), truly Copyright 2004 by The Society for Vascular Surgery.
doi:10.1016/j.jvs.2004.09.027 a universal document for CVD. It was endorsed by the joint JOURNAL OF VASCULAR SURGERYVolume 40, Number 6 Eklöf et al 1249
Table II. Members of American Venous Forum ad hoc
Table III. International ad hoc committee on revision of
committee on revision of CEAP classification Philip Coleridge Smith, MD, United Kingdom* Shunichi Hoshino, MD, JapanArkadiusz Jawien, MD, PolandNicos Labropoulos, MD, United StatesFedor Lurie, MD, United States councils of the Society for Vascular Surgery and the North American Chapter of the International Society for Cardio- Nick Morrison, MD, United StatesKenneth Myers, MD, Australia* vascular Surgery, and its basic elements were incorporated into venous reporting Today most published clinical papers on CVD use all or portions of the CEAP Hugo Partsch, MD, AustriaMichel Perrin, MD, France* OTHER DEVELOPMENTS RELATED TO CEAP
Eberhard Rabe, MD, GermanySeshadri Raju, MD, United States In 1998, at an international consensus meeting in Paris, Perrin et established a classification for recurrent vari- cose veins (Recurrent Varices After Surgery [REVAS]), the Jean Francois Uhl, MD, FranceMartin Veller, MD, South Africa evaluation of which is ongoing. In 2000 Rutherford et and the ad hoc Outcomes committee of AVF published an upgraded version of the original venous severity scoring system. The validity of the new severity score has beenevaluated by Meissner et and Kakkos et An evalua-tion of the system by 398 French angiologists was reported key members contributing in the interim to the revised document. The following passages summarize the results of Uhl et established a European Venous Registry these deliberations by describing the new aspects of the based on CEAP, and reported studies on intraobserver and interobserver variability that showed significant dis- The recommended changes, detailed below, include crepancies in the clinical classification of CEAP, which additions to or refinements of several definitions used in prompted improved definitions of clinical classes C to describing CVD; refinement of the C classification of CEAP; addition of the descriptor n (no venous abnormality An international consensus meeting in Rome in 2001 identified); incorporation of the date of classification and suggested definitions and refinements of the clinical classi- level of clinical investigation; and the description of “basic fication, the C in which were published with a CEAP,” introduced as a simpler alternative to the full commentary by the first author of the current revision of the venous reporting These not only contrib-uted to CEAP, but formed the basis for its ultimate modi- TERMINOLOGY AND NEW DEFINITIONS
The CEAP classification deals with all forms of CVDs.
The term “chronic venous disorder” includes the full spec- REVISION OF CEAP
trum of morphologic and functional abnormalities of the Diagnosis and treatment of CVD is developing rapidly, venous system, from telangiectasies to venous ulcers. Some and the need for an update of the classification logically of these, such as telangiectasies, are highly prevalent in the follows. It is important to stress that CEAP is a descriptive healthy adult population, and in many cases use of the term classification. Venous severity scoring was developed to “disease” is not appropriate. The term “chronic venous enable longitudinal outcomes assessment, but it became insufficiency” implies a functional abnormality of the ve- apparent that CEAP itself required updating and modifica- nous system, and is usually reserved for more advanced tion. In April 2002 an ad hoc committee on CEAP was disease, including edema (C ), skin changes (C ), or ve- appointed by AVF to review the classification and make recommendations for change by 2004, 10 years after its It was agreed to maintain the present overall structure introduction An international ad hoc committee of the CEAP classification, but to add more precise defini- was also established to ensure continued universal use tions. The following recommended definitions apply to the The 2 committees held 4 joint meetings, with 1250 Eklöf et al
atrophie blanche (white atrophy) Localized, often
C No visible or palpable signs of venous disease.
circular whitish and atrophic skin areas surrounded by C Telangiectasies or reticular veins.
dilated capillaries and sometimes hyperpigmentation. Sign C Varicose veins; distinguished from reticular veins by a
of severe CVD, and not to be confused with healed ulcer scars. Scars of healed ulceration may also exhibit atrophic skin with pigmentary changes, but are distinguishable by C Changes in skin and subcutaneous tissue secondary to
history of ulceration and appearance from atrophie blanche, CVD, now divided into 2 subclasses to better define the and are excluded from this definition.
corona phlebectatica Fan-shaped pattern of numer-
ous small intradermal veins on medial or lateral aspects of Lipodermatosclerosis or atrophie blanche.
ankle and foot. Commonly thought to be an early sign of advanced venous disease. Synonyms include malleolar flare C Healed venous ulcer.
C Active venous ulcer.
eczema Erythematous dermatitis, which may progress
Each clinical class is further characterized by a subscript to blistering, weeping, or scaling eruption of skin of leg.
for the presence of symptoms (S, symptomatic) or absence Most often located near varicose veins, but may be located of symptoms (A, asymptomatic), for example, C anywhere in the leg. Usually seen in uncontrolled CVD, Symptoms include aching, pain, tightness, skin irritation, but may reflect sensitization to local therapy.
heaviness, muscle cramps, and other complaints attribut- edema Perceptible increase in volume of fluid in skin
and subcutaneous tissue, characteristically indented withpressure. Venous edema usually occurs in ankle region, but REFINEMENT OF E, A, AND P CLASSES IN
lipodermatosclerosis (LDS) Localized chronic in-
flammation and fibrosis of skin and subcutaneous tissues of To improve the assignment of designations under E, A, lower leg, sometimes associated with scarring or contrac- and P a new descriptor, n, is now recommended for use ture of Achilles tendon. LDS is sometimes preceded by where no venous abnormality is identified. This n could be diffuse inflammatory edema of the skin, which may be added to E (E , no venous cause identified), A (A , no painful and which often is referred to as hypodermitis. LDS venous location identified), and P (P , no venous patho- must be differentiated from lymphangitis, erysipelas, or physiology identified). Observer variability in assigning cellulitis by their characteristically different local signs and designations may have been contributed to by lack of a systemic features. LDS is a sign of severe CVD.
normal option. Further definition of the A and P has also pigmentation Brownish darkening of skin, resulting
been afforded by the new venous severity scoring from extravasated blood. Usually occurs in ankle region, which was developed by the ad hoc committee on Out- comes of the AVF to complement CEAP. It includes not reticular vein Dilated bluish subdermal vein, usually 1
only a clinical severity score but a venous segmental score.
mm to less than 3 mm in diameter. Usually tortuous.
The venous segmental score is based on imaging studies of Excludes normal visible veins in persons with thin, trans- the leg veins, such as duplex scans, and the degree of parent skin. Synonyms include blue veins, subdermal vari- obstruction or reflux (P) in each major segment (A), and forms the basis for the overall score.
telangiectasia Confluence
This same committee is also pursuing a prospective mul- venules less than 1 mm in caliber. Synonyms include spider ticenter investigation of variability in vascular diagnostic labo- veins, hyphen webs, and thread veins.
ratory assessment of venous hemodynamics in patients with varicose vein Subcutaneous dilated vein 3 mm in di-
CVD. The last revision of the venous reporting still ameter or larger, measured in upright position. May involve cites changes in ambulatory venous pressure or plethysmo- saphenous veins, saphenous tributaries, or nonsaphenous graphically measured venous return time as objective mea- superficial leg veins. Varicose veins are usually tortuous, but sures of change. The current multicenter study aims to estab- tubular saphenous veins with demonstrated reflux may be lish the variability of, and thus limits of, “normal” for venous classified as varicose veins. Synonyms include varix, varices, return time and the newer noninvasive venous tests as an objective basis for claiming significant improvement as a result venous ulcer Full-thickness defect of skin, most fre-
of therapy, and it is hoped will provide improved reporting quently in ankle region, that fails to heal spontaneously and standards for definitive diagnosis and results of competitive DATE OF CLASSIFICATION
REFINEMENT OF C CLASSES IN CEAP
CEAP is not a static classification; disease can be reclas- The essential change here is the division of class C into sified at any time. Classification starts with the patient’s 2 subgroups that reflect severity of disease and carry a initial visit, but can be better defined after further investi- different prognosis in terms of risk for ulceration: gations. A final classification may not be complete until JOURNAL OF VASCULAR SURGERYVolume 40, Number 6 Eklöf et al 1251
after surgery and histopathologic assessment. We therefore In essence, basic CEAP applies 2 simplifications. First, recommend that any CEAP classification be followed by in basic CEAP the single highest descriptor can be used for clinical classification. For example, in a patient with varicoseveins, swelling, and lipodermatosclerosis the classification LEVEL OF INVESTIGATION
would be C . The more comprehensive clinical descrip- A precise diagnosis is the basis for correct classification of a venous problem. The diagnostic evaluation of CVD CEAP, when duplex scanning is performed, E, A, and P can be logically organized into 1 or more of 3 levels of should also be classified with the multiple descriptors rec- testing, depending on the severity of the disease: ommended, but the complexity of applying these to the 18 Level I: office visit, with history and clinical examina- possible anatomic segments is avoided in favor of applying tion, which may include use of a hand-held Doppler the simple s, p, and d descriptors to denote the superficial, perforator and deep systems. Thus, in basic CEAP the Level II: noninvasive vascular laboratory testing, which previous example, with painful varicosities, lipodermato- now routinely includes duplex color scanning, with some sclerosis, and duplex scan– determined reflux involving the plethysmographic method added as desired.
superficial and perforator systems would be classified as Level III: invasive investigations or more complex imag- ing studies, including ascending and descending venography,venous pressure measurements, computed tomography (CT),venous helical scanning, or magnetic resonance imaging REVISION OF CEAP AN ONGOING PROCESS
With improvement in diagnostics and treatment there We recommend that the level of investigation (L) will be continued demand to adapt the CEAP classification should also be added to the classification, for example, to better serve future developments. There is a need to incorporate appropriate new features without too frequent BASIC CEAP
disturbance of the stability of the classification. As one ofthe committee members (F. Padberg) stated in our delib- A new basic CEAP is offered here. Use of all compo- erations, “It is critically important that recommendations nents of CEAP is still encouraged. However, many use the for change in the CEAP standard be supported by solid C classification only, which is a modest advance beyond the research. While there is precious little that we are recom- previous classifications based solely on clinical appearance.
mending which meets this standard, we can certainly em- Venous disease is complex, but can be described with use of phasize it for the future. If we are to progress we should well-defined categorical descriptions. For the practicing focus on levels of evidence for changes rather than levels of physician CEAP can be a valuable instrument for correct investigation. While a substantial portion of our effort will diagnosis to guide treatment and assess prognosis. In mod- be developed from consensus opinion, we should still strive ern phlebologic practice most patients will undergo duplex scanning of the venous system of the leg, which will largelydefine the E, A, and P categories.
Nevertheless, it is recognized that the merits of using REVISION OF CEAP: SUMMARY
the full (advanced) CEAP classification system hold primar- Clinical classification
ily for the researcher and for standardized reporting inscientific journals. It enables grouping of patients so that C : no visible or palpable signs of venous disease those with the same types of disease can be analyzed to- gether, and such subgroup analysis enables their treatments to be more accurately assessed. Furthermore, reports that use CEAP can be compared with each another with much greater certainty. This more complex classification, for ex- C : lipodermatosclerosis or atrophie blanche ample, also allows any of the 18 named venous segments to be identified as the location of venous disease. For example, in a patient with pain, varicose veins, and lipodermatoscle- S: symptomatic, including ache, pain, tightness, skin rosis in whom duplex scans confirm primary reflux of the irritation, heaviness, and muscle cramps, and other greater saphenous vein and incompetent perforators in the complaints attributable to venous dysfunction While the detailed elaboration of venous disease in this form may seem unnecessarily complex, even intimidating, Etiologic classification
to some clinicians, it provides universally understandabledescriptions, which may be essential to investigators in the field. To serve the needs of both, the full CEAP classifica- tion, as modified, is retained as “advanced CEAP,” and the following simplified form is offered as “basic CEAP.” 1252 Eklöf et al
Anatomic classification
scanning on May 17, 2004, showed axial reflux of the great saphenous vein above and below the knee, incompetent calf perforator veins, and axial reflux in the femoral and popli- teal veins. There are no signs of postthrombotic Pathophysiologic classification
Classification according to basic CEAP: C Classification according to advanced CEAP: C Po: obstructionPr,o: reflux and obstruction REFERENCES
Pn: no venous pathophysiology identifiable 1. Beebe HG, Bergan JJ, Bergqvist D, Eklöf, B, Eriksson, I, Goldman MP, Advanced CEAP: Same as basic CEAP, with addition et al. Classification and grading of chronic venous disease in the lower that any of 18 named venous segments can be used as limbs: a consensus statement. Vasc Surg 1996;30:5-11.
2. Porter JM, Moneta GL, International Consensus Committee on Chronic Venous Disease. Reporting standards in venous disease: an 3. Perrin MR, Guex JJ, Ruckley CV, DePalma RG, Royle JP, Eklof B, et al.
Recurrent varices after surgery (REVAS): a consensus document. Car- 4. Rutherford RB, Padberg FT, Comerota AJ, Kistner RL, Meissner MH, Moneta GL. Venous severity scoring: an adjunct to venous outcome assessment. J Vasc Surg 2000;31:1307-12.
5. Meissner MH, Natiello C, Nicholls SC. Performance characteristics of the venous clinical severity score. J Vasc Surg 2002;36:89-95.
6. Kakkos SK, Rivera MA, Matsagas MI, Lazarides MK, Robless P, Belcaro G, et al. Validation of the new venous severity scoring system in varicose vein surgery. J Vasc Surg 2003;38:224-8.
7. Perrin M, Dedieu F, Jessent V, Blanc MP. Evaluation of the new severity Pelvic: gonadal, broad ligament veins, other scoring in chronic venous disease of the lower limbs: an observationalsurvey conducted by French angiologists. Phlebologie 2003;56:127- 8. Uhl JF, Cornu-Thenard A, Carpentier P, Schadek M, Parpex P, Chleir F. Reproducibility of the “C” classes of the CEAP classification. J Crural: anterior tibial, posterior tibial, peroneal veins 9. Allegra C, Antignani PL, Bergan JJ, Carpentier PH, Coleridge Smith P, Cornu-Thenard A, et al. The “C” of CEAP: suggested definitions andrefinements. An International Union of Phlebology conference of ex- Muscular: gastrocnemial, soleal veins, other 10. Moneta GL. A commentary of reference 9. J Vasc Surg 2003;37:224-5.
Submitted Aug 30, 2004; accepted Sep 28, 2004.
A patient has painful swelling of the leg, and varicose Additional material for this article may be found online veins, lipodermatosclerosis, and active ulceration. Duplex Table I, online only. Journals and books in which
CEAP classification has been published
Actualités Vasculaires Internationales 1995;31:19-22Angiologie 1995;47:9-16Angiology News 1996; 9:4-6Australia and New Zealand Journal of Surgery 1995;65:769-72Clinica Terapeutica 1997;148:521-6Dermatologic Surgery 1995;21:642-6Elleniki Angiochirurgiki 1996;5:12-9European Journal of Vascular and Endovascular Surgery 1996; Forum de Flebologia y Limphologia 1997;2:67-74Handbook of Venous Disorders 1996;652-60International Angiology 1995;2:197-201Japanese Journal of Phlebology 1995;1:103-8Journal of Cardiovascular Surgery 1997;38:437-41Journal of Vascular Surgery 1995;21:635-45Journal des Maladies Vasculaires 1995;20:78-83Mayo Clinic Proceedings 1996;71:338-45Minerva Cardioangiologica 1997;45:31-6Myakkangaku 1995;31:1-6Phlébologie – Annales Vasculaires 1995;48:275-81Phlebologie [German version] 1995;24:125-9Phlebology 1995;10:42-5Przeglad Flebologiczny 1996;4:63-73Scope on Phlebology and Lymphology 1996;3:4-7VASA 1995;24:313-8Vascular Surgery 1996;30:5-11

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