Regarding "The 'C' of CEAP: suggested definitions and refinements: an International Union of Phlebology conference of experts".

The International Union of Phlebology (IUP) Working Group has addressed an important subject in the field of chronic venous insufficiency. For decades, venous research, especially research concerning chronic venous insufficiency/venous ulceration, has skirted around on the fringe of respectability, lost in the netherworlds of phlebology and angiology and ignored by “main stream” vascular surgical academics on all continents. And yet, the patients are a component of virtually all academic vascular surgical practices but often only tolerated as the least desirable and least prestigious aspect of vascular surgical practice. Frequently, the venous patients are relegated to bandaging clinics or the clinic of the most junior member of the practice and are rarely seen by the professor. After all, everyone knows you treat venous insufficiency with compression and it does not take an Einstein to prescribe a stocking or place an UNNA boot or compressive bandage. Although there have been numerous reasons for the embarrassingly glacial pace of progress in chronic venous insufficiency research, a good part of the problem has been lack of communication among investigators in the field. Sure, meetings were held, papers were published, and professors traveled the world giving their opinions to whomever would listen. And yet, it was difficult to tell the details of the patient’s problem and incorporate published and presented information into one’s own practice. One physician’s idea of severe venous disease clearly differs from that of another physician. Unlike arterial occlusive disease patients who can largely be classified according to the ankle brachial index, no such simplistic measure of severity exists for patients with venous disease. Phlebography, plethysmography, ambulatory venous pressures, and duplex scanning all have their advocates and detractors. Vascular surgeons recognized the need, and subsequently embraced classification systems, for patients with arterial occlusive disease that reflected the clinical presentation of arterial patients while providing a measure of overall disease severity. Rutherford’s classification of lower extremity arterial occlusive disease in the United States and the Fontaine classification in Europe allowed clinical categorization of arterial patients that, along with the ankle brachial index, served to standardize descriptions of patients with lower extremity arterial occlusive disease. The importance of such universally recognized and utilized classification systems cannot be overemphasized. Their existence allows physicians in academic and private practice, and in all parts of the world, to relate published information to individual patients in individual practices. It is not necessary to speculate whether the published information applies to your patient; a good classification system combined with good reporting standards allows you to know. Guessing is minimized, and individual physicians’ patients have a greater opportunity to benefit from the experience of others. In 1994, an ad hoc committee of the American Venous Forum (AVF) met in Hawaii under the leadership of Bob Kistner and Bo Eklof as a component of a meeting organized by the Straub Foundation. The purpose of that AVF ad hoc committee was to develop a classification system of chronic venous disease that would parallel such systems in existence for arterial occlusive disease, the TNM system for cancer, or the CHAT system for carotid disease. The Hawaii meeting was chaired by Andrew Nicolaides who had extensive experience in leading conferences devoted to reaching consensus on difficult and complex issues. Out of this meeting, the CEAP classification system for chronic venous disease was created. The system provided a classification of chronic venous disease on the basis of clinical features (C), etiologic factors (E), the anatomy of disease distribution (A), and whether the underlying pathophysiology was reflux, obstruction, or both (P). CEAP has been widely publicized and widely accepted. It is now a component of the Journal of Vascular Surgery reporting standards for chronic venous disease. It has been published in eight languages on five continents and in 25 journals or textbooks. Some aspect of the CEAP system is employed in the large majority of papers currently published regarding chronic venous disease. The system is now, however, more than 8 years old, and some weaknesses have been recognized. Most attention has been focused on the “C” component of CEAP, and as pointed out in the IUP From the Division of Vascular Surgery, Department of Surgery, Oregon Health and Science University. Competition of interest: nil. J Vasc Surg 2003;37:224-5. Reprint requests: Gregory L. Moneta, MD, Vascular Surgery, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, OP-11, Portland, OR 97201-3098 (e-mail: monetag@ohsu.edu). Copyright © 2003 by The Society for Vascular Surgery and The American Association for Vascular Surgery. 0741-5214/2003/$30.00 0 doi:10.1067/mva.2003.46