CEAP Classification System for Chronic Venous Disease

Overview

The American College of Radiology defines the CEAP classification as a standardized system that categorizes chronic venous disease using four components—Clinical severity (C0‑C6), Etiology, Anatomic distribution, and Pathophysiology【1, 2, 3】.

Clinical severity is graded from C0 (no signs) to C6 (active ulcer), with each successive class representing a more severe manifestation【1, 2, 3】.
C1 denotes telangiectasia (intradermal veins < 1 mm) or reticular veins (subdermal veins 1‑3 mm)【1, 2】.
C2 describes varicose veins (dilated, tortuous subcutaneous veins ≥ 3 mm in the upright position)【1, 2】.
C3 corresponds to the presence of edema【1, 2】.
C5 indicates a healed venous ulcer【1, 2】.
C6 indicates an active venous ulcer【1, 2】.
Each clinical class can be further designated as asymptomatic or symptomatic【1, 2】.

The Etiology component identifies the underlying cause of venous disease【1, 2, 3】.
EP (primary venous disease) refers to valvular incompetence without an identifiable cause【1, 2】.

The Anatomic component specifies the venous segments involved【1, 2, 3】.
Superficial veins include the great saphenous vein, small saphenous vein, and their tributaries【1, 2】.
Deep veins include the femoral, popliteal, and tibial veins【1, 2】.
Perforator veins connect the superficial and deep systems【1, 2】.

The Pathophysiology component identifies the functional abnormality present【1, 2, 3】.
PO denotes venous obstruction as a pathophysiologic mechanism【1, 2】.

The CEAP system provides standardized terminology for clinical documentation, research reporting, and treatment planning【1, 2, 3】.

Approximately 25 % of the general population present with C2‑C3 disease, whereas about 5 % have C4‑C6 disease【1, 2, 3】.

Accurate anatomic and pathophysiologic designation requires objective diagnostic testing (e.g., duplex ultrasound, plethysmography, or venography)【1, 2】.
Clinical classification alone can be applied based on physical examination when imaging is unavailable【1, 2】.

The CEAP system defines seven clinical stages (C0–C6), with each higher stage indicating progressively more severe chronic venous disease, ranging from no visible signs (C0) to active venous ulceration (C6)【4】.
Stage C2 corresponds to varicose veins, defined as dilated, tortuous subcutaneous veins measuring ≥ 3 mm in diameter when the patient is upright【4】.

Approximately 25 % of the general adult population exhibits moderate disease (CEAP stages C2–C3)【4】.
About 5 % of the population has advanced disease (CEAP stages C4–C6)【4】.
Active venous ulcers (stage C6) affect roughly 1 % of people and represent the majority of chronic leg ulcers【4】.

Reflux: Valvular incompetence that produces retrograde (reverse) blood flow in the venous system【4】.
Obstruction: Any impediment to venous outflow that increases outflow resistance【4】.

All statements are supported by the American College of Radiology guidelines.【4】