The CEAP classification has been used as the reporting standard of chronic venous disease (CVD) since 1995 and was revised in 2004. The following are included in the CEAP classification revised in 2004: refinement of the definitions used in describing CVD, the division of class C4 into two subgroups, i.e., C4a (pigmentation or eczema) and C4b (lipodermatosclerosis or atrophie blanche), the addition of the descriptor “n” (no venous abnormality identified), the incorporation of the date of classification and level of clinical investigation, and the description of “basic CEAP” introduced as a simpler alternative to the advanced CEAP classification (
This review aims to elucidate the updated contents and the background of the 2020 update of the CEAP classifi-cation system.
The clinical classification (C) is the most widely used component of CEAP. Although the C classification is arranged such that more severe manifestations of venous disease are assigned a higher class, the clinical classification was not a quantitative severity scale or scoring system and is not designed to reflect changes over time (
The clinical definitions of each classification have been preserved since the last revision in 2004. As with the 2004 revision, basic CEAP for use in clinical practice should report the single highest C classification in a limb, and advanced (full) CEAP for the researcher and for standardized reporting in scientific journals should report all C classes present in the limb. Each clinical class should be further characterized by a subscript indicating the presence or absence of symptoms (symptomatic vs. asymptomatic) (
Recurrence of varicose veins (C2) and venous ulcers (C6) after intervention to correct reflux is common. In 1998, an international consensus group met in Paris and developed a classification for patients with recurrent varices after surgery (REVAS) to be used in conjunction with the CEAP classification. The clinical definition of REVAS is true recurrence, residual refluxing veins, and varicose veins caused by the progression of the disease. When the recurrence occurred on the same site of a previous operation, the causes could include tactical failure, technical failure, neovascularization, and disease progression (
Corona phlebectatica was first described in 1960 by Van der Molen (
Corona phlebectatica included three elements:
Telangiectasias, which are dilated intradermal venules, ramifications of “birch twigs” located at the medial or/and lateral aspects of the foot, nest to the malleolar areas. These lesions can be distinguished as blue or red.
Venous cups extend to the plantar arch as 6∼8 blue cups. These elements occur due to the dilatation of the triangular-shaped venous convergence coming from the plantar arch.
Stasis spots are made up of sub-epidermal capillaries, nummular, purple-colored areas.
The diagnosis of corona phlebectatica is determined by the presence of blue telangiectasias below the malleolar areas and/or stasis spots (
Proposed criteria for the grading of extension
|Grade 0||<5 telangiectases=C1 (no corona)|
|Grade I (incipient corona)||<half length of the foot|
|Grade II (definite corona)||≥half length of the foot|
Grade I: Incipient corona (or corona grade 1): more than five clusters of bluish intradermal veins in the sub-malleolar area.
Grade II: Definite corona (or corona grade 2): tortuous bluish intradermal veins with a diameter less than 3 mm in the sub-malleolar area, extended over the half length of the foot or more (Fig. 1).
The deciding characteristics to differentiate corona phlebectatica from telangiectasia of the ankle classified C1 are as follows (
More than five non-confluent intradermal veins.
The presence of stasis spots (clusters of dilated papillary capillaries).
An extension equal or superior to half the length of the foot (criterion of grade 2 corona phlebectatica).
Tiny areas of perivenous pigmentation.
Many phlebologists consider corona phlebectatica to be an early sign of advanced venous disease and to warrant inclusion in more advanced C categories. In the Venous Clinical Severity Score (VCSS), revised in 2010, corona phlebectatica was included in the VCSS scoring system but restricted to a score of “1” (mild) in the varicose veins score. Clinical data from a series of 872 patients evaluated by 49 angiologists from nine European countries demonstrated a statistical association between corona phlebectatica and clinical severity classes (
The clinical class in the 2020 update of the CEAP classification is presented in Table 2.
Clinical class in the 2020 update of the CEAP classification
|C0||No visible or palpable signs of venous disease|
|C1||Telangiectasias or reticular veins|
|C2r||Recurrent varicose veins|
|C4||Changes in skin and subcutaneous tissue secondary to chronic venous disease|
|C4a||Pigmentation or eczema|
|C4b||Lipodermatosclerosis or atrophie blanche|
|C6||Active venous ulcer|
|C6r||Recurrent active venous ulcer|
In the 2004 revision of the CEAP classification, there is no clear-cut description of the two different etiologies for secondary venous disease. Although clinical venous signs and symptoms are similar between intravenous and extravenous causes of venous disease, treatment options addressing different components are necessary. In the 2020 update of the CEAP classification, secondary etiologies of chronic venous disease are subcategorized into two subclasses (Esi and Ese).
Intravenous secondary causes of venous disease (ESi) are defined as any intravenous condition causing venous wall and/or valve damage, resulting from conditions such as deep vein thrombosis, traumatic arteriovenous fistulas, primary intravenous sarcoma, or other luminal changes inside the vein.
Extravenous secondary causes of venous disease (Ese) are defined as the condition affecting venous hemodynamics, either systemically (e.g., obesity and congestive heart failure) or locally by extrinsic compression (e.g., extravenous tumor, crossing iliac artery, and local perivenous fibrosis) with no venous wall or valve damage. Muscle pump dysfunction due to motor disorders (paraplegia, arthritis, chronic immobility, and frozen ankle) is also an extravenous secondary cause of venous disease since muscle pump dysfunction causes hemodynamic changes in the venous system of the lower extremity with no venous wall or valve damage (
The etiologic classification in the 2020 update of the CEAP classification is presented in Table 3.
Etiologic classification in the 2020 update of the CEAP classification
|Esi||Secondary – intravenous|
|Ese||Secondary – extravenous|
|En||No cause identified|
In the 2020 update of the CEAP classification, standard abbreviations of anatomical terms are used for the classifi-cation of vein segments instead of numbering since using numbers to denote venous segments is believed to be too difficult to effectively use, and the use of the abbreviations should increase the specificity and reproducibility of CEAP.
A summary of the anatomic classification (A) in the 2020 revision of CEAP is presented in Table 4.
Summary of the anatomic classification (A) in the 2020 update of the CEAP classification
|2.||GSVa||Great saphenous vein above knee|
|3.||GSVb||Great saphenous vein below knee|
|4.||SSV||Small saphenous vein|
|AASV||Anterior accessory saphenous vein|
|6.||IVC||Inferior vena cava|
|7.||CIV||Common iliac vein|
|8.||IIV||Internal iliac vein|
|9.||EIV||External iliac vein|
|11.||CFV||Common femoral vein|
|12.||DFV||Deep femoral vein|
|15.||TIBV||Crural (tibial) vein|
|15.||ATV||Anterior tibial vein|
|15.||PTV||Posterior tibial vein|
|17.||TPV||Thigh perforator vein|
|18.||CPV||Calf perforator vein|
|An||No venous anatomic location identified|
The P component of CEAP remains unchanged in the 2020 update of the CEAP classification (Table 5).
Pathophysiologic classification (P) in the 2020 update of the CEAP classification
|Pr,o||Reflux and obstruction|
|Pn||No pathophysiology identified|
In the 2020 update of the CEAP classification system, the clinical classification had the most dramatic revisions. Researchers should understand the definition of the recurrence of varicose veins and take into consideration that corona phlebectatica, which was classified as C1 (telangiectasia) in the CEAP revised in 2004, is newly classified as C4c in the 2020 update of the CEAP classification. The diagnosis of corona phlebectatica is determined by the presence of blue telangiectasias below the malleolar areas extending equal or superior to half the length of the foot and can be reinforced by stasis spot or perivenous pigmentation.