Before the mid-1990s, venous disorders and disease were classified almost solely on clinical appearance, which failed to achieve diagnostic precision or reproducible treatment results. In response to this, the American Venous Forum developed a classification system in 1994, which was revised in 2004. This classification system has gained widespread acceptance across the clinical and medical research communities, and most published papers now use all or part of the CEAP system (defined in the next section).¹ This system was once again updated in 2020.² These guidelines have value in their ability to provide consistency in the treatment of patients, which also results in greater efficacy, improved quality of care, and reduced cost.

Venous leg ulcers often involve a high level of costly care and can consume many medical resources, resulting in the need for specific guidelines to maximize the quality and effectiveness of care while also minimizing cost and resources used during the course of treatment.³

Diagnosis and Treatment of Venous Ulcers

Basic CEAP Explained

The basic CEAP system consists of two parts: classification and severity. Classification has four components: clinical manifestation, etiologic factors, anatomic distribution, and pathophysiologic dysfunction. Severity has four components: the number of anatomic segments affected, the grading of signs and symptoms, and disability.¹ The original CEAP classification system appeared as follows²:

• Clinical classification
  • C0 – No visible or palpable signs of venous disease
  • C1 – Telangiectasias or reticular veins
  • C2 – Varicose veins
    • C2r – Recurrent varicose veins
  • C3 – Edema
  • C4a – Pigmentation and/or eczema
  • C4b – Lipodermatosclerosis and/or atrophie blanche
  • C4c – Corona phlebectatica
  • C5 – Healed venous ulcer
  • C6 – Active venous ulcer
    • C6r – Recurrent venous ulcer
  • CS – Symptoms: Ache, pain, tightness, skin irritation, heaviness, muscle cramps, other complaints regarding venous function
  • CA – Asymptomatic
• Etiologic classification
  • Ec – Congenital – Condition present at birth but manifested later in life
  • Ep – Primary – Degenerative process of the venous valve and/or venous wall leading to floppy valve or vein wall weakness, resulting in some cases with venous reflux
  • Es – Secondary (post-thrombotic)
    • Esi – Intravenous
    • Ese - Extravenous
  • En – No venous etiology identified or those with clinical signs typically associated with venous disease if no other venous etiology is present
• Anatomic classification
  • As – Superficial veins
  • Ap – Perforator veins
  • Ad – Deep veins
  • An – No venous location identified
  • R – Right limb
  • L – Left limb
• Pathophysiologic classification
  • Pr – Reflux
  • Po – Obstruction
  • Pr,o – Reflux and obstruction
  • Pn – No venous pathophysiology identifiable

Later Additions and Revisions, Including the Venous Clinical Severity Score

In addition to the CEAP classification, the Venous Clinical Severity Score (VCSS) was introduced in 2000 and revised in 2010 as a complement to the CEAP system. This system includes 10 clinical descriptors, scored from 0 to 3 with 0 indicating no presence and 3 indicating severe presence. The VCSS can have a score that totals between 0 and 30 to provide physicians with a method for assessing changes to therapy. This system includes the following descriptors⁴:

• Pain
  • 0 – No pain
  • 1 – Occasional pain
  • 2 – Daily pain or discomfort that interferes but does not prevent daily activities
  • 3 – Daily pain
• Varicose veins (smaller than 3 mm to qualify in standing position)
  • 0 – None
  • 1 – Few scattered, including corona phlebectatica
  • 2 – Confined to calf or thigh
  • 3 – Involves calf and thigh
• Venous edema
  • 0 – None
  • 1 – Limited to foot and ankle area
  • 2 – Extends above ankle but below knee
  • o3 – Extends to knee and above
• Skin pigmentation
  • 0 – None or focal
  • 1 – Limited to perimalleolar area
  • 2 – Diffuse over lower third of calf
  • 3 – Wider distribution above lower third of calf
• Inflammation
  • 0 – None
  • 1 – Limited to perimalleolar area
  • 2 – Diffuse over lower third of calf
  • 3 – Wider distribution above lower third of calf
• Induration
  • 0 – None
  • 1 – Limited to perimalleolar area
  • 2 – Diffuse over lower third of calf
  • 3 – Wider distribution above lower third of calf
• Active ulcer number (0 = 0, 1 = 1, 2 = 2, 3 = 3 or more)
• Active ulcer duration
  • 1 - Less than three months
  • 2 – Between three months and one year
  • 3 – Greater than one year
• Active ulcer size
  • 1–2 cm or less in diameter
  • 2–2-6 cm in diameter
  • 3–diameter greater than 6 cm
• Use of compression therapy
  • 0 – Not used
  • 1 – Intermittent use of stockings
  • 2 – Wears stockings most days
  • 3 – Always wears stockings (full compliance)

In addition to the VCSS, the Advanced CEAP classification system includes 18 named venous segments that can be used as locators for venous disease. These names include⁵:

• Superficial veins
  • Telangiectasias or reticular veins
  • Great saphenous vein above knee
  • Great saphenous vein below knee
  • Lesser saphenous vein
  • Non-saphenous veins
• Deep veins
  • Inferior vena cava
  • Common iliac vein
  • Internal iliac vein
  • External iliac vein
  • Pelvic: gonadal, broad ligament veins, other
  • Common femoral vein
  • Deep femoral vein
  • Femoral vein
  • Popliteal vein
  • Crural: anterior tibial, posterior tibial, peroneal veins
  • Muscular: gastrocnemius, soleus veins, other
• Perforating veins
  • Thigh
  • Calf

Assessing Venous Leg Ulcers

The accurate classification of venous disease is critical in understanding venous disease severity and the assessment of treatment efficacy. The CEAP classification system and the VCSS can be used to follow clinically defined changes over time. When using these systems, there are several things to keep in mind²:

• A VCSS score of 8 or more indicates a patient with severe disease that warrants additional diagnostics or treatment.
• Additional patient evaluations may be used to provide a more comprehensive assessment, such as a patient-oriented quality of life assessment.
• Outcome assessment can be used to determine the success of interventions over time.

Conclusion

Classification systems, and particularly CEAP for venous leg ulcers, can provide a solid foundation for understanding a patient's unique ulcer characteristics. When used correctly, these tools can be incredibly helpful in identifying and selecting the most appropriate treatment course.

References

1. American Venous Forum. CEAP & Venous Severity Scoring. https://www.veinforum.org/medical-allied-health-professionals/avf-initi…. Accessed December 19, 2019.

2. Venous News. (2020, March). Revision of CEAP classification recognises new predictors and definitions for venous disease. 2020. https://venousnews.com/revision-ceap-classification-venous-disease-avf-…. Accessed March 27, 2020.

3. O'Donnell TF, Passman MA, Marston WA, et al. Management of venous leg ulcers: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg. 2014;60(2):3S-59S.

4. American Venous Forum. Revised Venous Severity Score. https://www.veinforum.org/wp-content/uploads/2019/05/Revised-VCSS-AVF.p…. Accessed December 19, 2019.

5. American Venous Forum. Revision of the CEAP Classification: Summary. https://www.veinforum.org/wp-content/uploads/2018/03/Revised-CEAP-Class…. Accessed December 19, 2019.