CEAP — classification of chronic venous disorders

Interactive tool

Build the classification

Fill in the four axes: the builder generates the full (advanced) CEAP string and the basic version, ready to paste into the report.

How to use it

Instructions

The four axes

The C class is followed by S if the patient is symptomatic (pain, aching, tightness, heaviness, skin irritation, muscle cramps and other complaints attributable to venous dysfunction) or A if asymptomatic.

Basic and advanced CEAP

• Basic CEAP reports only the highest clinical class and the generic codes of the other three axes: it is sufficient for routine clinical practice and outpatient reporting.
• Advanced CEAP lists all the clinical classes present and specifies the individual anatomic segments involved, using the abbreviations introduced in 2020. It is required in clinical research, registries and pre-operative documentation.
• Good practice is to record the date of the classification and the level of investigation (Level I clinical examination with or without hand-held Doppler; Level II duplex ultrasound; Level III invasive or complex imaging such as venography, CT, MR or IVUS): CEAP is a snapshot, and without date and method it loses value at follow-up.

Clinical references

Guidelines and interpretation

What CEAP does and does not do

CEAP is a descriptive classification, not a severity scale and not a treatment guide. Two C2 patients may have completely different clinical pictures and indications. Severity is graded with the VCSS; impact on quality of life is measured with a dedicated questionnaire (CIVIQ-20, AVVQ, VEINES-QOL).

A structural limitation is that the C class does not fall below the highest level reached: a healed ulcer keeps the patient in C5 permanently, even after fully successful treatment. CEAP is therefore insensitive to change and should not be used as an outcome measure.

The role of duplex ultrasound

The A and P axes cannot be completed from the clinical examination alone: they require venous duplex ultrasound (Level II). The ultrasound report should explicitly provide the elements needed to build them:

• Reflux: duration > 0.5 seconds in superficial veins, deep calf veins and the deep femoral vein; > 1.0 second in the common femoral, femoral and popliteal veins. A perforator is considered pathological when outward flow lasts ≥ 0.5 seconds, its diameter is ≥ 3.5 mm and it lies beneath a healed or active ulcer (C5–C6).
• Obstruction: non-compressibility, intraluminal material, loss of respiratory phasicity, development of collateral pathways, abnormal response to the Valsalva manoeuvre.
• The examination for reflux is performed with the patient standing or in reverse Trendelenburg; the provocation manoeuvres used should be described in the report.
• Mapping of escape and re-entry points, saphenous trunk diameters and junctional competence.

Link with clinical decisions

The post-thrombotic patient

In patients with previous deep vein thrombosis the etiology is Esi and the pathophysiology is often Pr,o: reflux from valve destruction coexists with obstruction from organised residual thrombus. In these cases CEAP should be supplemented with the Villalta score, the specific tool for post-thrombotic syndrome, and any iliocaval obstruction should be assessed, as it may be an indication for recanalisation with stenting.

References

Sources

• Lurie F. et al., J Vasc Surg Venous Lymphat Disord 2020 — The 2020 update of the CEAP classification system and reporting standards.
• Eklöf B. et al., J Vasc Surg 2004 — Revision of the CEAP classification for chronic venous disorders: consensus statement.
• Gloviczki P. et al., J Vasc Surg Venous Lymphat Disord 2023–2024 — The 2022 SVS/AVF/AVLS clinical practice guidelines for the management of varicose veins of the lower extremities, Parts I and II.
• De Maeseneer MG. et al., Eur J Vasc Endovasc Surg 2022 (ESVS) — Clinical practice guidelines on the management of chronic venous disease of the lower limbs.