Chronic venous insufficiency is caused be venous reflux, or backward flow in the venous system. This produces venous hypertension, magnified in distal parts of the legs where gravity exerts its effects most profoundly. Recalling that venous flow in the legs normally goes from distal to proximal and superficial to deep, valve failure along these circuits leads to elevated pressures in the venous segments with progressive failure of neighboring valves as elevated pressures are propagated.
A consensus conference of leading phlebologists has developed the commonly accepted classification of venous insufficiency, from clinical class 1 to clinical class 6.
C.E.A.P. Classification for Venous Disease
The C.E.A.P. Classification for venous disease is a method of stratifying patients according to the severity of their presentation. CEAP stands for:
- Clinical
- Etiologic
- Anatomic
- Pathophysiologic
There was an elaborate scoring system developed which these main categories and broke them down to many fine criteria with which to compare patients. The system was cumbersome to use given the variability of presentation of vein problems. The usage of CEAP has been simplified to designate CEAP categories 1–6.
The CEAP categories are as follows:
- Reticular and spider veins
- Varicose veins
- Varicose veins and leg swelling
- Varicose veins and evidence of venous stasis skin changes
- Varicose veins and a healed venous stasis ulceration
- Varicose veins and an open venous ulceration
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CEAP Class 1
Superficial spider veins (reticular veins) only. |
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CEAP Class 2
Simple varicose veins only. |
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CEAP Class 3
Ankle edema (due to venous disease). The venous congestion, often due to saphenous vein incompetence, may lead to dependent edema. Elimination of the venous reflux often gives dramatic results. |
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CEAP Class 4
Skin pigmentation in the gaiter area (e.g. lipodermatosclerosis, medical calf fibrosis). The hemosiderin deposition in the medical subcutaneous leg causes the pigmentation changes an can also lead to mild chronic inflammation leading to fibrosis. |
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CEAP Class 5
A healed venous ulcer. Elevated venous pressures may lead to relative tissue hypoxia, which causes skin fragility and ulceration. Restoration of normal venous hemodynamics leads to ulcer healing. |
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CEAP Class 6
An open venous ulcer. Venous hypertension changed the perfusion gradients which let to this ulcer. Once the refluxing saphenous vein was ablated and venous flow normalized, the ulcer began to heal quickly. |
Recommendations for new patients with venous disease:
CEAP 1: No Need to refer for medical treatment, cosmetic problem only.
CEAP 2: Refer routinely to Vein specialist for duplex & photoplethysomography assessment.
CEAP 3-5: Refer quickly to Vein specialist for duplex ultrasound & photoplethysomography assessment.
CEAP 6: Refer urgently to Vein specialist for duplex ultrasound & photoplethysomography assessment & to Wound Care Center for ulcer assessment.
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