Refinement Of Cclasses In Ceap

The essential change here is the division of class C 4 into two subgroups that reflect different severity of disease, and carry a different prognosis in terms of risk of ulceration:

C0: No visible or palpable signs of venous disease

C1: Telangiectasies or reticular veins

C2: Varicose veins—distinguished from reticular veins by a diameter of 3 mm or more C3: Edema

C4: Changes in the skin and subcutaneous tissue secondary to CVD (now divided into two subclasses to better define the differing severity of venous disease): C4a: Pigmentation and/or eczema C4b: Lipodermatosclerosis and/or atrophie blanche C5: Healed venous ulcer C6: Active venous ulcer

Each clinical class is further characterized by a subscript for the presence of symptoms (S, symptomatic) or absence of symptoms (A, asymptomatic), for example, C2A or C5S. Symptoms include aching, pain, tightness, skin irritation, heaviness, and muscle cramps, as well as other complaints attributable to venous dysfunction.


To improve the assignment of designations under E, A, and P, a new descriptor n is now recommended for use where no venous abnormality is identified. This n could be added to E (En: no venous etiology identified), A (An: no venous location identified), and P (Pn: no venous patho-physiology identified). Observer variability in assigning designations in the past may have been contributed to by the lack of a normal option. Further definition of the A and P has also been afforded by the new venous severity scoring system,12 which was developed by the ad hoc Committee on Outcomes of the AVF to complement CEAP. It includes not only a Clinical Severity Score but a Venous Segmental Score. The latter is based on imaging studies of the leg veins, for example, duplex scan, and the degree of obstruction or reflux (P) in each major segment (A) and forms the basis for the overall score.

This same committee also is pursuing a prospective multicenter investigation of variability in vascular diagnostic laboratory assessment of venous hemodynamics in patients with CVD. The last revision of the venous reporting standards11 still cites changes in ambulatory venous pressure or plethysmographically measured venous return time (VRT) as objective measures of change. The current multicenter study aims to establish the variability of, and thus limits of "normal" for, the VRT and the newer noninvasive venous tests as an objective basis for claiming significant improvement as a result of therapy, and will hopefully provide improved reporting standards for definitive diagnosis and results of competitive treatments in patients with CVD.

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