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April 20, 2020

2020 Update Published for the CEAP Classification System and Reporting Standards for Chronic Venous Disorders

April 20, 2020—The 2020 update of the CEAP (Clinical-Etiology-Anatomy-Pathophysiology) classification system and reporting standards has been published by Fedor Lurie, MD, et al in Journal of Vascular Surgery: Venous and Lymphatic Disorders (JVS-VL; 2020;8:342–352).

As stated in the document, the CEAP classification system is based on clinical manifestations of chronic venous disorders, on the current understanding of the etiology, the involved anatomy, and the underlying venous pathology. It is an internationally accepted standard for describing patients with chronic venous disorders and it is used for reporting clinical research findings in scientific journals.

The document notes that the CEAP classification was developed in 1993, updated in 1996, and revised in 2004. In 2017, the American Venous Forum (AVF) created a CEAP Task Force and charged it to critically analyze the current classification system and recommend revisions. As the evidence related to these aspects of venous disorders, and specifically of chronic venous diseases (CVD; C2–C6) continue to develop, the CEAP classification needs periodic analysis and revisions, stated the authors.

To adopt the revised Delphi process and make several changes, the Task Force was guided by four basic principles: (1) preservation of the reproducibility of CEAP, (2) compatibility with previous versions, (3) evidence-based, and (4) practical for clinical use.

The report in JVS-VL describes the revisions and the rationale for making these changes, which include:

  • Adding Corona phlebectatica as the C4c clinical subclass
  • Introducing the modifier “r” for recurrent varicose veins and recurrent venous ulcers
  • Replacing numeric descriptions of the venous segments by their common abbreviations

The conclusion of the document states, “Since its initial development, the CEAP classification has been and continues to be an important contributor to progress in the field of CVD. It has become a universally accepted standard in research and reporting. Although the stability of classification is essential for maintaining scientific and clinical advancement, continuously accumulated evidence and knowledge require revisiting the classification and its definitions and revising them when necessary.”

Furthermore, the authors advised, “This 2020 CEAP revision is a result of a rigorous process of evidence analysis. Although several proposed changes were not included in the final version, proponents of these and other future potential revisions are encouraged to develop and publish supporting evidence. When such evidence is available, the AVF Task Force will revisit the CEAP classification system, making revisions as part of a continual process and maintaining the integrity of CEAP as the universally accepted classification system and reporting standard for CVD.”

An accompanying editorial in JVS-VL is authored by Bo Eklöf, MD (2020;8:341). Dr. Eklöf, of Lund University in Helsingborg, Sweden, was a leader in the creation of the first CEAP classification system in 1993 and is a co-author of the 2020 update.

In his commentary, Dr. Eklöf stated, “In CVDs, reliance for too long was placed on the clinical appearance of the limb and the superficial veins, without requiring objective testing of the venous system to substantiate the diagnosis. Previous classifications from Widmer (1978) through Miranda (1993) lacked completeness and objectivity needed for scientific accuracy.”

Beginning in 1993, Dr. Eklöf and leading pioneers developed classification systems for diagnosis and treatment of chronic venous disease. The classifications evolved to keep up with advancements in CVD treatment. He noted that by 2016, many authors have used CEAP for publications most used only the clinical classification C and not the complete CEAP.

In addition to the four principles noted above, Dr. Eklöf stressed a fifth principle of the task force: “The goal to keep CEAP as a discriminative instrument while the Venous Disease Severity Score should be its evaluative complement.”

He stated in JVS-VL, “[T]he new recommendations were implemented, with easy to understand explanations of definitions, affecting three of the four categories of CEAP:

  • C: C2r and C6r were introduced for recurrence; corona phlebectatica C4c was added, which will please our colleagues in France and Italy
  • E: the subcategory of Es was introduced
  • A: anatomic abbreviations were used and not numbers
  • P: no change”

Dr. Eklof concluded, “The AVF task force, under the leadership of Fedor Lurie and Mark Passman, has done an excellent job with the latest, second revision and with explanation of the important role of CEAP in CVD. Publication of this document appears to be a good reason to remind reviewers and editors to require the complete CEAP—basic or advanced—classification for manuscripts dealing with CVD to improve the scientific quality of published literature. By not adhering to these principles, we may be back where we were 40 years ago, using Widmer's clinical classification.”

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