Revision of CEAP classification recognises new predictors and definitions for venous disease

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Marc Passman
Marc Passman

Incorporating evidence collected since 2004, the latest revision of the CEAP (Clinical-Etiology-Anatomy-Pathophysiology) classification system has underlined a number of key updates relating to descriptions of chronic venous disease patients. “There has been a lot of information that has come out over the last 15 years that required parts of CEAP to change,” said Marc Passman (University of Alabama, Birmingham, USA), presenting at the annual meeting of the American Venous Forum (VENOUS 2020; 3–6 March, Amelia Island, USA).

Revealing the new CEAP classification for 2020 alongside first author Fedor Lurie (Jobst Vascular Institute, Toledo; University of Michigan, Ann Arbor, USA), Passman continued by emphasising the “wide acceptance for the CEAP system across all venous societies internationally”, as well as the fact that this revision aims to “enhance our collective understanding of venous disease and elevate scientific standards for published literature”.

“The challenge for our taskforce was to figure out how to change the system while maintaining the integrity of the 2004 version, but also provide meaningful updates to move CEAP forward. Also important was the need to avoid time delay for research and evidence synthesis,” he added.

During the session chaired by Passman and Lurie, in which the latter also outlined the methodology of the update, each of the team leaders—who focused and led a review on one of the four components of the CEAP classification—explained the most significant changes, if any, to the system.

With regard to the “Clinical” element, Mark Meissner (University of Washington School of Medicine, Seattle, USA) asserted that CEAP is reproducible, evidence-based, and places a low burden on practicing clinicians, as well as noting two additions to “C”. Corona phlebectatica will now be recognised as “a predictor of ulceration similar to other advanced skin changes (C4c)”, while recurrent disease will also be recognised as part of the system (e.g. C2r for recurrent varicose veins and C6r for recurrent venous ulcer).

Elna Masuda (University of Hawaii, Honolulu, USA) presented a revision of the “Etiology” component, which included changes to descriptions of venous disease. For “None” (En), which was previously attributed to patients with no venous abnormality, those who possess clinical signs typically associated with venous disease can now come under the parameters of this description, if no other typical venous aetiology is found.

In “Congenital” (Ec) cases, an adjustment, from “congenital abnormality which may be apparent at birth or can be recognised later”, to “condition present at birth, but manifested later in life”, was made. A new definition for primary venous disease—a “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”—has also been established.

Finally, secondary venous disease has been separated into intravenous (Esi) and extravenous (Ese), with the former a condition causing venous wall and/or valve damage, and the latter a pathology affecting venous haemodynamics, locally or systematically.

In major revisions to the “Anatomy” section of CEAP, detailed by Harold Welch (Lahey Hospital and Medical Center, Burlington, USA), it has been affirmed that any limb being reported for venous disease “should be identified as Right(R) or Left (L)”. Moreover, Welch stressed the need to use specific anatomic abbreviations instead of numbers.

On the “Pathophysiology” element, Ruth Bush (University of Houston College of Medicine, Houston, USA) commented that although there were no significant changes as part of this revision, “contributing factors that may stand alone as pathophysiological mechanisms or in conjunction with valvular incompetence or reflux” include a BMI of less than 30kg/m2, right heart failure, impaired calf muscle pump function, or valvular incompetence in smaller veins.


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