CEAP: The Key to the Initial Consultation
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By: Paul M. McNeill, MD FACS Visit VeinGlobal at http://www.veinglobal.com/ for more presentations and videos on this topic, or for more information on venous disease news, education and research.
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CEAP: The Key to the Initial Consultation
- 1. Paul M. McNeill, MD FACS Capitol Vein and Laser Center Maryland, Virginia, Washington, DC CEAP: The Key to the initial consultation
- 2. CEAP: initial consultation C Clinical E Etiologic A Anatomic P Pathophysiologic
- 3. CEAP: initial consultation Two Levels Basic CEAP Full CEAP
- 4. CEAP: initial consultation C Clinical E Etiologic A Anatomic P Pathophysiologic
- 5. CEAP: initial consultation C Physical Exam Inspection Palpation Auscultation Musculoskeletal
- 6. CEAP: initial consultation C Physical Exam Inspection Palpation Auscultation Musculoskeletal
- 7. CEAP: initial consultation C Physical Exam Inspection Palpation Auscultation Musculoskeletal
- 8. CEAP: initial consultation C Physical Exam Inspection Palpation Auscultation Musculoskeletal
- 9. CEAP: initial consultation C Physical Exam Inspection Palpation Auscultation Musculoskeletal
- 10. CEAP: initial consultation C C1 Telangiectasia C2 Varicose Veins C3 Edema C4 Skin Changes C5 Healed Ulcer C6 Active Ulcer CA,S Symptoms
- 11. CEAP: initial consultation C C1 Telangiectasia C2 Varicose Veins C3 Edema C4 Skin Changes C5 Healed Ulcer C6 Active Ulcer CA,S Symptoms
- 12. CEAP: initial consultation C C1 Telangiectasia C2 Varicose Veins C3 Edema C4 Skin Changes C5 Healed Ulcer C6 Active Ulcer CA,S Symptoms
- 13. CEAP: initial consultation C C1 Telangiectasia C2 Varicose Veins C3 Edema C4 Skin Changes C5 Healed Ulcer C6 Active Ulcer CA,S Symptoms
- 14. CEAP: initial consultation C C1 Telangiectasia C2 Varicose Veins C3 Edema C4 Skin Changes C5 Healed Ulcer C6 Active Ulcer CA,S Symptoms
- 15. CEAP: initial consultation C C1 Telangiectasia C2 Varicose Veins C3 Edema C4 Skin Changes C5 Healed Ulcer C6 Active Ulcer CA,S Symptoms
- 16. CEAP: initial consultation C C1 Telangiectasia C2 Varicose Veins C3 Edema C4 Skin Changes C5 Healed Ulcer C6 Active Ulcer CA,S Symptoms
- 17. CEAP: initial consultation Symptoms of Venous Disease Tingling Aching Fatigue or leg tiredness Cramping Restless legs Focal pain Swelling Sensations of throbbing or Heaviness Itching skin
- 18. CEAP: initial consultation C CA: Asymptomatic Tingling Aching Fatigue or leg tiredness Cramping Restless legs Focal pain Swelling Sensations of throbbing or Heaviness Itching skin
- 19. CEAP: initial consultation C Clinical E Etiologic A Anatomic P Pathophysiologic
- 20. CEAP: initial consultation E Etiologic Ec Congenital Es Secondary Ep Primary
- 21. CEAP: initial consultation E Etiologic Ec Congenital Es Secondary Ep Primary
- 22. CEAP: initial consultation E Etiologic Ec Congenital Es Secondary Ep Primary
- 23. CEAP Anatomic Classification C Clinical E Etiologic A Anatomic P Pathophysiologic
- 24. CEAP: Anatomic
- 25. CEAP Full Anatomic Classification Segment Number # Name # Name 1 Telangectasia, reticular 10 Pelvic 2 GSV above knee 11 Common femoral Vein 3 GSV below knee 12 Deep Femoral Vein 4 Small saphenous vein 13 Femoral 5 Non-saphenous vein 14 Popliteal Vein 6 Inferior vena cava 15 Crural veins 7 Common iliac vein 16 Muscular veins 8 Internal iliac vein 17 Thigh perforator vein 9 External iliac vein 18 Calf perforator vein
- 26. CEAP Basic Anatomic Classification Anatomic Classification As Superficial Ap Perforating Ad Deep An No location identified
- 27. CEAP Basic Anatomic Classification Anatomic Classification As Superficial Ap Perforating Ad Deep An No location identified
- 28. CEAP Anatomic Classification A C2SEpAsPr A Anatomic s category 2 segment number
- 29. CEAP Anatomic Classification A C2SEpAsPr A Anatomic s category 2 segment number
- 30. CEAP Anatomic Classification A C2SEpAsPr2 A Anatomic s category 2 segment number
- 31. CEAP Anatomic Classification A C2SEpAsPr A Anatomic s category 2 segment number
- 32. CEAP Anatomic Classification C Clinical E Etiologic A Anatomic P Pathophysiology
- 33. CEAP Pathophysiology Classification Pathophysiology Pr Reflux Po Obstruction Pr,o Both Pn None Identified
- 34. Consultation Telangiectasia 1 Varicose veins 2 Edema 3 Symptomatic s C3s
- 35. Consultation Telangiectasia 1 Varicose veins 2 Edema 3 Symptomatic s Etiology – Primary p C3sEp
- 36. Anatomic GSV above knee s SSV s Tibial vein reflux d Telangiectasia s C3EpAs,d
- 37. Pathophysiologic GSV above knee s SSV s Tibial vein reflux d Telangiectasia s Pathophysiology r C3EpAs,dPr
- 38. CEAP Classification C3 Edema CS symptomatic Ep Primary As,d Superficial, Deep Pr Reflux C3sEpAs,dPr
- 39. CEAP Classification Level of Evaluation 1 History, exam, doppler 2 Duplex 3 Invasive or Complex Date of Evaluation C3sEpAs,dPr
- 40. CEAP Classification Level of Evaluation 1 History, exam, doppler 2 Duplex 3 Invasive or Complex Date of Evaluation C3sEpAs,dPr(Level 2, April 23, 2014)
- 41. Consultation Telangiectasia 1 Varicose veins 2 Pigmentation 4 Symptomatic s C4s
- 42. Etiology Telangiectasia 1 Varicose veins 2 Pigmentation 4 Symptomatic s Etiology - Secondary s C4sEs
- 43. Anatomy Common Fem Vein d GSV s C4sEsAs,d
- 44. Pathophysiology Common Fem Vein d GSV s Pathophysiology r C4sEsAs,dPr
- 45. Anatomy Common Fem Vein d GSV s Pathophysiology r Level of investigation 2 Date of evaluation C4sEsAs,dPr(Level 2, April 4, 2014)
- 46. CEAP: initial consultation C Clinical E Etiologic A Anatomic P Pathophysiologic
- 47. Paul M. McNeill, MD FACS Capitol Vein and Laser Center Maryland, Virginia, Washington, DC CEAP: The Key to the initial consultation Next – Venous Clinical Severity Score
- 48. Paul M. McNeill, MD FACS Capitol Vein and Laser Center Maryland, Virginia, Washington, DC CEAP: The Key to the initial consultation
Editor's Notes
- The CEAP Classification is an established guide to initial patient consultation. The foundation of our clinical decision making in vein care comes from the accurate evaluation and classification of the underlying venous disorder.
- CEAP was developed by the American Venous Forum in 1994 and revised to its current form in 2004. The classification is based on the clinical signs of venous disease (C), the Etiology (E), Anatomy (A) and underlying pathophysiology (P) Next: There are two levels of detail with CEAP: Basic and Full
- The Basic CEAP Classification is suitable for use in clinical practice. The Full CEAP Classification applies more significant detail and is used in research. Next: Clinical C stands for Clinical.
- C stands for Clinical. This refers to the Clinical presentation including the history and physical examination.
- C stands for Clinical. This refers to the Clinical examination. A complete clincal examination includes: Inspection Telangiectasia Varicosities Edema Erythema Pigmentation Coronaphlebectasia Lipodermatosclerosis Ulceration Next: Inspection – veins above the inguinal ligament
- Physical findings such as these veins of the anterior abdominal wall can indicate iliac vein obstruction Next: Palpation
- P is Palpation Palpation Evidence of thrombosis Tenderness Edema Pulses Masses – leg, groin or abdomen Lipomas Adenopathy Facial defects – often confused with varicose veins Joint fluid is fluctuant Joints can be painful on palpation if inflamed Next is Auscultation Less frequently employed Sudden onset leg swelling or vein engorgement of the lower leg may be secondary to Tricuspid insufficiency An arterio-venous fistula can be appreciated with a stethoscope
- Auscultation Less frequently employed Sudden onset leg swelling or vein engorgement of the lower leg may be secondary to Tricuspid insufficiency An arterio-venous fistula can be appreciated with a stethoscope Secondary to percutaneous interventions including placement of tumescent anesthesia during ablation Next Examination of hip, knee and ankle
- Musculoskeletal exam: Joint mobility and pain Hip Knee Ankle Leg pain in the region of varicose veins may be secondary to a musculoskeletal etiology Next: Clinical categories
- Next – symptoms of vein disease
- The Symptoms of Venous Disease Include Tingling Aching Fatigue or leg tiredness Cramping Restless legs Focal pain Swelling Sensations of throbbing or Heaviness Itching skin It is important to be familiar with these symptoms because many patients and physicians do not recognize that such symptoms occur with venous insufficiency and erroneously determine that the patient is asymptomatic C stands for Clinical. This refers to the Clinical presentation including the history and physical examination. Inspection Telangiectasia Varicosities Edema Erythema Pigmentation Coronaphlebectasia Lipodermatosclerosis Ulceration Palpation Evidence of thrombosis Tenderness Edema Pulses Masses – leg, groin or abdomen Auscultation Bruit Joint mobility and pain Hip Knee ankle
- This patient presnted with a painful episode of phlebitis in a large group of varicose veins based off the GSV. The thrombotic process extended into the GSV Her asymptomatic status delayed her from evaluation until after this occurred. She will likely have longstanding pigmentation of the leg. Removal of veins such as these is difficult. NEXT Etiology
- The Etiology of the venous disease is considered in formulating the evaluation and treatment plan It is important to differentiate between primary, secondary and congenital causes of venous insufficiency.
- Congenital reflux exists from birth but is rarely recognized early. Congenital reflux accounts for 1-3% of all reflux. Patients presenting very early in life with significant varicose veins, leg swelling or symptoms of venous insufficiency may have congenital reflux.
- The Etiology of the venous disease is considered in formulating the evaluation and treatment plan Secondary reflux is usually the result of thrombosis. Secondary reflux accounts for 18 to 28% of CVD. Thrombotic events in the lower extremity are common and can be secondary to thrombophilia, injury, surgery or defect in the vein wall or low flow states such as occurs with immobility during travel or with convalescence.
- In Primary Reflux the cause has not been determined. This is actually the most common type accounting for 64 to 79% of all CVD. Patients often inquire about whether they inherited their varicose vein condition from their family.
- Anatomic distribution is divided into three sub-categories: There are 18 named segments of veins from the inferior vena cava to the foot
- The segments and their pathology are identified by venous duplex in the leg and other modalities in the abdomen A complete duplex exam will be discussed later today. Interrogation of deep and superficial veins, perforating veins and Venous outflow from the leg are accomplished and documented.
- Here are the 18 named segments of veins from the infradiaphragmatic inferior vena cava to the foot. In Basic CEAP we describe only Superficial, Deep and Perforating veins.
- The BASIC anatomic classification is simplified. There is also the category “n” for No location identified.
- I have had patients such as this who are symptomatic and have stigmata of venous disease without a specific anatomic location identified as the site of reflux.
- The capitol letter A is followed by the category identifying the site of reflux – Next slide here in this case the “s” for superficial
- here in this case the “s” for superficial This is how the anatomy is described in the Basic CEAP. In full CEAP……..
- In full CEAP…….. There is a segment number – here its “2” for GSV above the knee. The numbers for the segments are placed at the end of the description
- In Basic CEAP, only the category is noted.
- The Pathophysiology comes last. It’s the letter “P”
- There are 4 categories in Pathophysiology Reflux Obstruction Both none
- So here is an example of a patient presenting for consultation The patient is Symptomatic Has Telangiectasia Varicose veins And Edema In Basic CEAP, the highest category is used to designate the clinical status – Edema – which is 3.
- Etiology is primary varicose veins Designated by the letter p S is secondary and C is congenital
- The pathophysiology here is Reflux Other categories are Obstruction Both Reflux and obstruction None identified
- Two final elements of the CEAP Classification system are the Date of the evaluation and the level of the diagnositic evaluation with Level 1 – History, physical examination and handheld doppler Level 2 – Venous duplex examination and plethysmography Level 3 – invasive or complex evaluation – venography, Venous pressure, IVUS, CT, MRI
- Two final elements of the CEAP Classification system are the Date of the evaluation and the level of the diagnositic evaluation with Level 1 – History, physical examination and handheld doppler Level 2 – Venous duplex examination and plethysmography Level 3 – invasive or complex evaluation – venography, Venous pressure, IVUS, CT, MRI
- So here is an example of a patient presenting for consultation The patient is Symptomatic Has Telangiectasia Varicose veins And Pigmentation In Basic CEAP, the highest category is used to designate the clinical status – Edema – which is 3.
- The patient’s varicose veins developed after a DVT in the Left Common Femoral Vein. The patient has deep vein reflux as well as superficial reflux Es In Basic CEAP, the highest category is used to designate the clinical status – Edema – which is 3.
- The pathophysiology is reflux Pr
- The duplex ultrasound shows Reflux in the Saphenofemoral junction, the GSV and the femoral vein The patient had a DVT years ago and now has reflux in the SFJ, GSV and CFV
- The duplex ultrasound shows Reflux in the Saphenofemoral junction, the GSV and the femoral vein
- So your understanding of the CEAP Classification and your use of the Classification in the process of patient care ensures that you have considered all the aspects of the patient’s presentation. CEAP guides you through the patient evaluation step by step and sets the stage for good decision making. If you establish the CEAP classification for your patient, you have considered their circumstance thoughtfully. Having patients classified according to CEAP in your documentation communicates with clarity to third party payers as well as fellow physicians.
- The CEAP Classification is an accurate description of the clinical presentation and patient anatomy. We will next discuss the utility of the Venous Clinical Severity Score in adding another element in understand your patient and following their response to your care.