Revision of the CEAP classification for chronic venous disorders: Consensus statement

Revision of CEAP

Diagnosis and treatment of CVD is developing rapidly, and the need for an update of the classification logically follows. It is important to stress that CEAP is a descriptive classification. Venous severity scoring ⁴was developed to enable longitudinal outcomes assessment, but it became apparent that CEAP itself required updating and modification. In April 2002 an ad hoc committee on CEAP was appointed by AVF to review the classification and make recommendations for change by 2004, 10 years after its introduction . An international ad hoc committee was also established to ensure continued universal use. The 2 committees held 4 joint meetings, with key members contributing in the interim to the revised document. The following passages summarize the results of these deliberations by describing the new aspects of the revised CEAP.

In essence, basic CEAP applies 2 simplifications. First, in basic CEAP the single highest descriptor can be used for clinical classification. For example, in a patient with varicose veins, swelling, and lipodermatosclerosis the classification would be C_4b. The more comprehensive clinical description, in advanced CEAP, would be C_2,3,4b. Second, in basic CEAP, when duplex scanning is performed, E, A, and P should also be classified with the multiple descriptors recommended, but the complexity of applying these to the 18 possible anatomic segments is avoided in favor of applying the simple s, p, and d descriptors to denote the superficial, perforator and deep systems. Thus, in basic CEAP the previous example, with painful varicosities, lipodermatosclerosis, and duplex scan–determined reflux involving the superficial and perforator systems would be classified as C_4b,S, E_p,A_s,p, P_r, rather than C_2,4b,S, E_p,A_s,p, P_r2,3,18.

Revision of CEAP an ongoing process

With improvement in diagnostics and treatment there will be continued demand to adapt the CEAP classification to better serve future developments. There is a need to incorporate appropriate new features without too frequent disturbance of the stability of the classification. As one of the committee members (F. Padberg) stated in our deliberations, “It is critically important that recommendations for change in the CEAP standard be supported by solid research. While there is precious little that we are recommending which meets this standard, we can certainly emphasize it for the future. If we are to progress we should focus on levels of evidence for changes rather than levels of investigation. While a substantial portion of our effort will be developed from consensus opinion, we should still strive to achieve an evidence-based format.”

Example

A patient has painful swelling of the leg, and varicose veins, lipodermatosclerosis, and active ulceration. Duplex 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 popliteal veins. There are no signs of postthrombotic obstruction.

Classification according to basic CEAP: C_6,S, E_p,A_s,p,d, P_r.

Classification according to advanced CEAP: C_2,3,4b,6,S, E_p,A_s,p,d, P_{r2,3,18,13,14} (2004-05-17, L II).

Sclerotherapy is to be considered in our patients ?

In routine practice, a 0.5% or 1% concentration of foam sclerosant is preferred for vessels less than 5 mm in diameter, while 2% and 3% concentrations are used for vessels larger than 5 mm in diameter. In one ex-vivo study they were unable to demonstrate any statistically significant results among different foam concentrations on 5-10 mm diameter vessels in terms of pathological damage. However, due to the near significant difference between the outcomes of 0.5% and 1% foam sclerosants, the use of 1% foam sclerosant instead of 0.5% may be preferable. Again, 1% foam sclerosant may be preferred to 2% or 3% in larger vessels, as it exerts more severe damage on the vein wall. Further studies are necessary to validate these findings. We have been using the 1% sclerosant for vessels between 5 -10 mm diameters for the past few years without significant recanalizaiton or residual varicosities. Axial veins seem to be more resistant to obliteration by the sclerotherapy compared to the tributaries in clinical practice.