CEAP is a standardised classification system of venous disorders that enables the systematic description of any patient with chronic venous disease according to their C-clinical signs, E-etiology, A-anatomic distribution and the P-pathophysiology of their disease.
| Clinical Classification (C) | Aetiologic Classification (E) |
| C0 No visible/palpable signs of venous disease | EC Congenital |
| C1 Telangiectasia or reticular veins | EP Primary |
| C2 Varicose Veins | ES Secondary (post-thrombotic) |
| C3 Oedema | En No venous aetiology identified |
| C4a Pigmentation &/or eczema | Anatomic Classification (A) |
| C4b Lipodermatosclerosis &/or atrophy | AS Superficial veins |
| C5 Healed venous ulcer | AP Perforator |
| C6 Open (non-healed) venous ulcer | Ad Deep veins |
| An No venous location identified | |
| Subscript | Pathophysiologic Classification (P) |
| A Asymptomatic | Pr Reflux |
| S Symptomatic | PO Obstruction |
| Pr,o Reflux & obstruction | |
| Pn No venous pathophysiology identified |
National and International Treatment Guidelines based on CEAP Classification
National and International Clinical Guidelines are relatively consistent in their treatment recommendations for VV and CVD. They recommend treatment related to the severity of venous disease as determined by the CEAP Classification [10, 11, 15]:
Reticular Veins and Spider Veins (C0 and C1)
- Any patients with C0 and C1, with no evidence of GSV reflux require reassurance and/or conservative treatment with compressions stockings.
- If symptoms such as muscle cramps are present, medical treatment can be trialled under medical supervision and continued as long as there is a treatment benefit.
- Periodic clinical and ultrasonographic examination may be indicated to monitor for progression of disease and to guide interventional treatment with disease progression/when indicated.
Varicose Veins (C3)
- Guideline recommendations for treatment options for varicose veins depend on the severity of the visible veins and ultrasound findings, in particular the presence and location of venous reflux.
- Early varicose veins with minimal reflux of the main truncal veins (GSV and SSV) should have a trial of conservative treatment and symptom management with compression stockings, with or without a trial of venoactive agents.
- As VV and CVD are progressive diseases any patient with early reflux changes should be monitored on a regular basis (at least annually) with clinical review and venous duplex ultrasound. This will enable the early identification of disease progression and discussion of treatment options.
- Varicose veins with presence of truncal (GSV/SSV) incompetence is an indication for interventional treatment. The mainstay of any interventional treatment is to occlude/remove the incompetent truncal veins and occlude/ligate perforating veins to treat the source of venous reflux. Treatment of the visible venous tributaries and small vein disease (spider and reticular veins) are secondary priorities but should be included in any treatment plan. Current intervention options include endovenous treatment (ELVA, RFA or CAC) or surgical management. Choice of interventional option is related to the underlying disease and skills of the treating surgeon.
- Whilst Surgical and Endovenous treatments provide similar short-term and long-term results regarding occlusions rates there are progressive recommendations towards endovenous treatments of EVLA, RFA or CAC with their many advantages, including: treatment in the ambulatory setting, early mobilisation and return to work/usual activities.
Varicose Veins with complications/Chronic Venous Insufficiency with various complications (C4-C6)
- All current guidelines recommend interventional management of patients with varicose veins or CVI with truncal (GSV/SSV) reflux and any complication (C4-C6). Interventional treatment for the underlying truncal venous incompetence, venous perforator disease and venous tributary disease should be performed in-line with treatment options, as detailed for uncomplicated varicose veins (above).
- The aims of treatment are to occlude the underlying incompetent veins/perforators, prevent progression of disease, improve reversible complications and healing of any active ulcer disease. Leg oedema, visible varicosities and open wounds are potentially reversible with treatment of underlying CVD. Skin changes including haemosiderosis, atrophie blanche and lipodermosclerosis may show some improvements, but are not reversible despite adequate treatment.
Management of Patients with Active Venous Ulcers (C6):
There is increasing clinical and health economics evidence that patients with open venous ulcers benefit from a multidisciplinary team approach. Treatment of the underlying venous disease, in conjunction with wound management, results in a faster time to heal and a better long term outcome[14].