Overview of Venous Leg Ulcers

Venous leg ulcers (VLUs) comprise approximately 70% to 90% of chronic leg ulcers. These wounds can take years to heal, and even after healing, they often recur.¹ Risk factors include older age and female sex,^1,2 as well as a family history of chronic venous insufficiency, a high body mass index, a history of pulmonary embolism or superficial or deep venous thrombosis, lower extremity musculoskeletal disease, multiple pregnancies, physical inactivity, a history of ulcers, and deep venous reflux.² 

VLU diagnosis begins with a complete history and physical examination. Although most leg ulcers are venous, other causes should be sought when an ulcer is atypical, present for more than 6 months, or nonhealing with standard care.¹ Biopsy may help establish a diagnosis,¹ and various imaging modalities are used to pinpoint venous obstruction.³ The Venous Clinical Severity Score (VCSS) is an important diagnostic tool, as is the CEAP (Clinical, Etiological, Anatomical, Pathophysiological) classification.

CEAP Classification: Background and History

CEAP is a classification system based on clinical features of chronic venous disorders (CVDs), their origin, relevant anatomy, and underlying pathologic processes.⁴ The CEAP classification relies on our present understanding of CVDs, and that changes as we continue to learn.⁵ 

The CEAP classification is a descriptive (discriminative) classification, including the full range of morphologic and functional abnormalities of the venous system. In contrast, the VCSS and quality of life scoring systems are evaluative tools for longitudinal research to assess outcomes.^5,6

Until the development of the CEAP classification, the diagnosis of CVDs was not clearly delineated.⁶ Reporting errors in studies of venous diseases led John Porter, at a meeting of the American Venous Forum in 1993, to suggest a classification for venous disease analogous to the TNM system used for cancer.³ In 1994, the American Venous Forum created the CEAP classification to standardize the diagnosis of venous diseases, and the CEAP classification was incorporated into the Reporting Standards in Venous Disease the following year.³ The CEAP classification was adopted globally as a basis for better communication on CVD management among researchers, and it was also used clinically for diagnosis, documentation, and treatment planning.⁶

In 2004, the American Venous Forum and an international committee recommended several additions to the CEAP classification. They also devised a basic version of CEAP classification as an alternative to the full (advanced) CEAP classification.⁶ The basic CEAP classification was simplified for office use, and the comprehensive CEAP classification was intended for research.⁷

In 2017, the American Venous Forum formed a Task Force to analyze the current CEAP classification and suggest revisions. The Task Force added a new subclass and replaced numbers with abbreviations of conditions.⁴

The CEAP classification was revised again in 2020, and this is in current use.^4,8 Revisions will be ongoing, to ensure that the CEAP remains universally accepted and the standard for reporting CVDs.⁴

The 2020 CEAP Classification

The 2020 CEAP classification contains the following categories:⁴

 ^aAdvanced CEAP: New abbreviations for specific A anatomic location(s) to be reported under each P pathophysiologic class to identify anatomic location(s) corresponding to P class.

CEAP Use in Clinical Diagnosis

The CEAP classification in patients with venous disorders is used to distinguish primary venous disease from congenital varicosity as well as from secondary post-thrombotic venous insufficiency. (To grade disease severity, the VCSS is used.)⁷

With the CEAP classification, health care professionals can document CVD diagnoses accurately by using the abbreviations of each component of disease (Clinical, Etiological, Anatomical, Pathophysiological). Rather than write a long description of the patient and imaging results, clinicians can easily create a compact CEAP formula that contains this information.⁵ 

The CEAP classification does have a limitation, however, in that it focuses only on CVDs such as VLUs. Given that chronic conditions can arise from acute events, and acute conditions can become chronic or can complicate chronic diseases, it would be helpful to include some relevant acute conditions in future CEAP revisions.⁵

To streamline documentation even further, digital applications have become available to calculate CEAP classifications quickly.⁵ An internet search revealed that various manufacturers are offering these applications. 

CEAP Use in Monitoring Healing and Response to Treatment

The CEAP classification is first determined at the patient’s presenting visit is updated as needed.⁶ Ongoing use of the CEAP classification and the VCSS is advisable to identify and document disease severity and evaluate the patient’s response to treatment.⁹

Potential risk factors for failure of a VLU to heal include treatment disparity factors, disease-specific factors, and systemic factors systemic factors.¹⁰ Unfavorable prognostic signs for healing include VLU duration lasting more than 3 months, initial ulcer length of 10 cm or longer, lower extremity arterial disease, advanced age, and elevated body mass index.² Elements of these factors can be categorized in the CEAP classification.

A study measuring preoperative and postoperative CEAP classifications in patients who underwent endovenous ablation for varicose veins showed improved CEAP classifications after the procedures.¹¹

Conclusion

The CEAP classification is a valuable contribution to the diagnosis and management of CVDs, including VLUs, and future revisions will ensure the continued relevance of this rightly acclaimed system. 

References

1. Hess CT. Venous ulcer assessment and management: using the updated CEAP classification system. Adv Skin Wound Care. 2020;33(11):614-615.

2. Bonkemeyer Millan S, Gan R, Townsend PE. Venous ulcers: diagnosis and treatment. Am Fam Physician. 2019;100(5):298-305.

3. Zegarra TI, Tadi P. CEAP Classification of venous disorders. [Updated 2023]. In: StatPearls [Internet]. StatPearls Publishing; 2025. Accessed January 10, 2025. https://www.ncbi.nlm.nih.gov/books/NBK557410/

4. Lurie F, Passman M, Meisner M, et al. The 2020 update of the CEAP classification system and reporting standards. J Vasc Surg Venous Lymphat Disord. 2020;8(3):342-352. Published correction in J Vasc Surg Venous Lymphat Disord. 2021;9(1):288. 

5. Carman T, Lurie F. CEAP 2020: understanding and applying the updated chronic venous disease classifications. Endovascular Today. 2020. Accessed January 10, 2025. https://evtoday.com/articles/2020-july/ceap-2020-understanding-and-applying-the-updated-chronic-venous-disease-classifications

6. Eklöf B, Rutherford RB, Bergan JJ, et al; American Venous Forum International Ad Hoc Committee for Revision of the CEAP Classification. Revision of the CEAP classification for chronic venous disorders: consensus statement. J Vasc Surg. 2004;40(6):1248-1252.

7. Gloviczki P, Comerota AJ, Dalsing MC, et al; Society for Vascular Surgery; American Venous Forum. The care of patients with varicose veins and associated chronic venous diseases: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg. 2011;53(5 suppl):2S-48S.

8. Eklöf B. New revision of the 25-year-old CEAP classification is timely and warranted. J Vasc Surg Venous Lymphat Disord. 2020;8(3):341.

9. Pascarella L, Shortell CK. Medical management of venous ulcers. Semin Vasc Surg. 2015;28(1):21-28.

10. Melikian R, O’Donnell TF Jr, Suarez L, Iafrati MD. Risk factors associated with the venous leg ulcer that fails to heal after 1 year of treatment. J Vasc Surg Venous Lymphat Disord. 2019;7(1):98-105.

11. Bendix SD, Peterson EL, Kabbani LS, Weaver MR, Lin JC. Effect of endovenous ablation assessment stratified by great saphenous vein size, gender, clinical severity, and patient-reported outcomes. J Vasc Surg Venous Lymphat Disord. 2021;9(1):128-136.