**8. Classification**

The Chronic Venous Disorders (CVD) Guideline was released for the Clinical, Etiologic, Anatomic and Pathophysiologic (CEAP) classification in 1994 by American Venous Forum, which is an international ad-hoc committee, and was endorsed by the Society for Vascular Surgery. It was incorporated into "Reporting Standards in Venous Disease" in 1995. Nowadays, clinical papers released on CVD use the whole or some parts of CEAP classification to determine features of disease [31].

The purpose of the CEAP classification is to provide an objective classification system that is valid and reliable throughout the world. This classification identifies the clinical symptoms (C), etiologic factors (E), anatomical features (A) and underlying pathophysiological event (P) [32, 33]. Detailed information is given in **Table 1**.

The clinical classification has seven categories (between 0 and 6) and is further categorized by the presence or absence of symptoms. The etiologic classification is based on congenital, primary and secondary causes of venous dysfunction [34]. The anatomic classification describes the superficial, deep and perforating venous systems with multiple venous segments that may be involved. The pathophysiologic classification describes the underlying mechanism resulting in CVI, including reflux, venous obstruction or both [6].

*C0:* This refers to early the disease stages and there is usually not any visible or palpable sign of venous disease. Despite the fact that sometimes no clinical evidence is found by the physicians during the examination; clinically CVI is manifested by the presence of some symptoms such as aching legs, heaviness, sensation of burning and nocturnal cramps. Depending on the


severity of the symptoms, there may not be a significant change in the patient's daily life or it may cause significant limitations on the patients.

*C1:* Telangiectasia (dilated intradermal venules up to a size of about 1 mm) and reticular varicose veins (dilated, nonpalpable and subdermal veins up to a size of about 4 mm). These signs which are associated with increased venous pressure and chronic venous insufficiency occur due to the capillary disorder.

*C2:* There are several dilated and simultaneously elongated varicose veins. Varicose veins according to etiologic origins are classified as primary (idiopathic), secondary (caused by the post-thrombotic syndrome) and other secondary varicose veins of unclear etiology.

*C3:* Swelling is one of the most frequent signs of CVI. It is characterized by the accumulation of proteins and water in subcutaneous tissues. While in lying position, the swellings tend to disappear; in long-standing position, swelling increases and causes significant limitations in the daily life of the patients.

*C4:* As CVI progresses, changes on the skin begin to be observed. On this stage pigmentation, eczema and lipodermatosclerosis are common findings.

*C5:* Venous ulcers, which are defined as a loss of skin tissue, may develop on the skin in the following periods. Skin changes with healed ulcer are seen in this stage. Only healed varicose ulcers are included within the class 5.


*C6:* This class is defined by the presence of an active varicose ulcer [35].

**Table 2.** Venous clinical severity scoring.

**8. Classification**

126 Clinical Physical Therapy

mine features of disease [31].

**C0**

**C1**

**C2**

**C3**

**C4**

**C5**

**C6**

on the skin

atrophie blanche

veins

disease

: There is no sign of venous

: Telangiectases or reticular

: Pigmentation or eczema

**C4b**: Lipodermatosclerosis or

: Healed venous ulcer

: Active venous ulcer

**Table 1.** CEAP classification system.

: Varicose veins **Es:** Secondary (post-

: Edema **En:** There is no cause

Detailed information is given in **Table 1**.

resulting in CVI, including reflux, venous obstruction or both [6].

The Chronic Venous Disorders (CVD) Guideline was released for the Clinical, Etiologic, Anatomic and Pathophysiologic (CEAP) classification in 1994 by American Venous Forum, which is an international ad-hoc committee, and was endorsed by the Society for Vascular Surgery. It was incorporated into "Reporting Standards in Venous Disease" in 1995. Nowadays, clinical papers released on CVD use the whole or some parts of CEAP classification to deter-

The purpose of the CEAP classification is to provide an objective classification system that is valid and reliable throughout the world. This classification identifies the clinical symptoms (C), etiologic factors (E), anatomical features (A) and underlying pathophysiological event (P) [32, 33].

The clinical classification has seven categories (between 0 and 6) and is further categorized by the presence or absence of symptoms. The etiologic classification is based on congenital, primary and secondary causes of venous dysfunction [34]. The anatomic classification describes the superficial, deep and perforating venous systems with multiple venous segments that may be involved. The pathophysiologic classification describes the underlying mechanism

*C0:* This refers to early the disease stages and there is usually not any visible or palpable sign of venous disease. Despite the fact that sometimes no clinical evidence is found by the physicians during the examination; clinically CVI is manifested by the presence of some symptoms such as aching legs, heaviness, sensation of burning and nocturnal cramps. Depending on the

**Clinical Etiologic Anatomic Pathophysiologic**

thrombotic, post-traumatic)

determined

**Ec:** Congenital **As:** Superficial veins **Pr:** Reflux

**Ep:** Primary **Ap:** Perforator veins **Po:** Obstruction

**An:** There is no venous location identified

**Ad:** Deep veins **Pr,o:** Reflux and

obstruction

**Pn:** There is no venous pathophysiology determined

To complement the CEAP classification and further define the severity of CVI, the venous clinical severity score (VCSS) was developed (**Table 2**) [36, 37]. The revised VCSS provides clarification of the terms and better definition of the descriptors and has further clinical applicability [38].

The VCSS consists of 10 attributes with four grades (absent, mild, moderate and severe). It has been shown to be useful in evaluation of the response to treatment in CVI. To evaluate severity of disease and treatment outcomes in CVI, it is recommended to make use of validated diseasespecific quality-of-life questionnaires in clinical evaluations [39].
