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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
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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
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