Chronic venous disorders (CVD), particularly varicose veins, constitute one of the most common vascular conditions globally, affecting approximately 20–30% of the adult population [1]. Characterized by dilated, tortuous superficial veins, varicose veins arise due to valvular incompetence within the venous system, leading to venous hypertension and progressive venous insufficiency. This condition encompasses a spectrum of symptoms ranging from cosmetic concerns and mild discomfort to severe complications including skin changes and venous ulcers [2].

The burden of CVD is not limited to patient morbidity alone; it exerts substantial healthcare costs and economic loss due to diminished productivity and prolonged treatment requirements. Patients often present with leg pain, swelling, heaviness, night cramps, or complications such as lipodermatosclerosis and non-healing ulcers, all of which significantly impair quality of life [3]. The management of varicose veins has evolved significantly with the advent of newer diagnostic modalities, minimally invasive procedures, and targeted therapy options. However, accurate clinical classification remains central to guiding treatment and prognostication.

To standardize the assessment and facilitate comparison of clinical data, the CEAP (Clinical-Etiological-Anatomical-Pathophysiological) classification system was introduced by the American Venous Forum in 1994 and later revised in 2004 [4]. This comprehensive classification integrates clinical presentation, underlying etiologies, anatomical distribution, and pathophysiological mechanisms of venous disease. Among its components, the ‘C’ or Clinical classification is most commonly applied in routine clinical practice, ranging from C0 (no visible signs) to C6 (active venous ulceration) [5]. Although CEAP classification provides a valuable framework, questions remain regarding its predictive value and correlation with clinical outcomes. Several studies have suggested that increasing CEAP class correlates with worsening symptomatology and poorer prognostic indicators, yet most available data are retrospective or cross-sectional in nature, with limited prospective validation [6]. Moreover, the integration of patient-reported outcome measures such as the Venous Clinical Severity Score (VCSS) and Aberdeen Varicose Vein Questionnaire (AVVQ) into CEAP-based stratification remains underutilized [7].

In this context, a prospective evaluation of CEAP classification and its association with objective clinical outcomes is warranted. Understanding how clinical stages relate to disease burden, ulcer healing, and recurrence risk may enhance clinical decision-making and enable more precise stratification of therapy. Furthermore, validating CEAP staging through prospective outcome correlations may reinforce its relevance as a prognostic tool across varied healthcare settings [8].

The present study aims to prospectively evaluate the CEAP classification in patients with varicose veins and correlate clinical stages with outcome measures such as symptom severity, quality of life, ulcer healing duration, and recurrence rates. By integrating Doppler-confirmed anatomical findings with validated scoring systems and follow-up outcomes, this study intends to fill existing gaps in literature and provide robust evidence to support CEAP-based clinical stratification in routine practice [9].

This prospective observational study was conducted in the Department of General Surgery Government Medical College, Mahabubabad over a period of 12 months from April 2024 to March 2025. The study was approved by the Institutional Ethics Committee, and informed consent was obtained from all participants.

Study Design and Population

A total of 150 adult patients presenting to the outpatient or emergency department with clinical features of primary varicose veins of the lower limbs were included. Inclusion criteria comprised patients aged 18 years and above, of either sex, with clinically and Doppler-confirmed lower limb varicosities classified under CEAP class C2 to C6. Exclusion criteria included patients with recurrent varicose veins, deep vein thrombosis (DVT), secondary venous disease due to trauma or neoplasia, pregnant women, and those with concurrent peripheral arterial disease or unfit for follow-up.

Data Collection

Upon enrollment, detailed history including symptom duration, occupational profile, family history, and comorbidities was obtained. Physical examination findings were recorded and CEAP classification assigned based on the 2004 revised criteria. All patients underwent color Doppler ultrasonography to confirm anatomical sites of venous reflux or obstruction. Each patient’s condition was objectively graded using the Venous Clinical Severity Score (VCSS) and subjectively using the Aberdeen Varicose Vein Questionnaire (AVVQ) at baseline.

Interventions, if any (e.g., compression therapy, sclerotherapy, or surgical management), were recorded. Patients were followed up at 1, 3, and 6 months post-intervention or post-enrollment (in conservatively managed cases). Clinical outcomes evaluated included symptom improvement, ulcer healing time (in C5–C6 patients), and recurrence or deterioration in CEAP class. Compliance with compression therapy and complications were also noted.

Statistical Analysis

Data were analyzed using IBM SPSS Statistics for Windows, Version 26.0 (IBM Corp., Armonk, NY). Continuous variables (e.g., VCSS, AVVQ scores) were expressed as mean ± standard deviation (SD). Categorical variables (e.g., CEAP class, presence of ulcers, recurrence) were expressed as frequencies and percentages. Associations between CEAP class and outcome measures were assessed using chi-square tests for categorical data and one-way ANOVA for continuous data. A p-value < 0.05 was considered statistically significant. Confidence intervals (95%) were reported where applicable.

Ethical Considerations

The study adhered to the ethical principles outlined in the Declaration of Helsinki. Participants were informed about the nature, risks, and benefits of the study, and were free to withdraw at any point without affecting their standard of care. Data confidentiality was strictly maintained.

This structured methodology ensured consistent assessment of CEAP classification and its relationship with clinical outcomes across the study cohort.

Table 1: Baseline Demographic Profile of Study Participants

Table 2: Clinical Stage Distribution Based on CEAP Classification

Table 3: Correlation between CEAP Class and Disease Burden Scores

Table 4: Clinical Outcomes Observed During Follow-up (6 Months)

Table 5: Treatment Modalities Stratified by CEAP Class

Among the 150 patients evaluated, the mean age was 45.8 years, with a predominance of males (56.7%) and a majority residing in urban areas (60%). Occupational exposure to prolonged standing was present in 64.7%, a known risk factor for venous insufficiency. Notably, 21.3% reported a positive family history, suggesting a hereditary predisposition. Clinical staging using the CEAP system revealed that most patients presented at C3 (edema, 38.0%) and C2 (varicosities without edema, 27.3%). Severe stages (C5 and C6), indicative of ulcerative disease, each accounted for 10% of the cohort. This suggests that while the majority presented with moderate disease, a significant subset progressed to advanced stages, often with delayed presentation.

The disease burden, as measured by Venous Clinical Severity Score (VCSS), increased progressively with CEAP class: from 5.4 ± 1.2 in C2 to 11.3 ± 2.0 in C6. A similar trend was seen with Aberdeen Varicose Vein Questionnaire (AVVQ) scores, which escalated from 10.4 ± 2.3 to 25.2 ± 3.6. The bar graph clearly illustrated this linear correlation, reinforcing the association between clinical stage and symptom severity (p < 0.001). Ulcer healing was exclusively observed in C5 and C6 groups. Mean healing time was 6.2 ± 1.4 weeks in C5 and significantly prolonged in C6 (8.1 ± 1.9 weeks). Recurrence rates showed a parallel trend, being lowest in C2 (2.4%) and highest in C6 (20.0%).Treatment modality shifted notably across CEAP classes. Conservative therapy dominated in C2 (61.0%) and C3 (52.6%), while invasive interventions became more common in advanced stages, especially C6 (80.0%). This shift reflects increased severity and poor response to conservative measures in later stages.

Varicose veins, a visible manifestation of chronic venous insufficiency, remain a prevalent yet frequently under-recognized vascular disorder with significant morbidity. This prospective study reaffirms the clinical utility of the CEAP classification system in stratifying disease severity and predicting outcomes across various stages of venous disease.

The rationale for this study stemmed from the need to validate the prognostic relevance of CEAP staging using objective clinical markers. While CEAP is universally adopted, prior literature has questioned its correlation with patient outcomes such as symptom burden, ulcer healing, and recurrence rates. By integrating CEAP staging with validated scoring systems like VCSS and AVVQ, this study aimed to bridge this knowledge gap.

In alignment with findings from Mallick et al. [10] and Garcia et al. [11], our results demonstrated a strong positive correlation between CEAP class and both VCSS and AVVQ scores. Patients classified as C6 exhibited the highest mean VCSS (11.3 ± 2.0) and AVVQ scores (25.2 ± 3.6), indicating more severe clinical and quality-of-life impairment. This trend was consistent with the observations reported by Rabe et al. [12], suggesting that CEAP staging not only reflects anatomical disease but also mirrors symptom progression. Ulcer healing times and recurrence rates also escalated with disease stage. In our cohort, mean healing time was 8.1 ± 1.9 weeks in C6 patients, with a recurrence rate of 20%, comparable to studies by Lattimer et al. [13] and Gohel et al. [14], which reported recurrence rates of 18–23% in similar populations. Notably, early-stage patients (C2–C3) experienced minimal complications and favorable outcomes with conservative therapy, underscoring the importance of early intervention.

The treatment patterns observed also mirrored disease progression. While conservative management was sufficient in over 60% of C2 patients, the shift toward surgical or laser intervention in C5–C6 (over 70%) was statistically significant. This finding parallels conclusions by Siribumrungwong et al. [15], who noted the declining efficacy of compression therapy alone in ulcerative disease. Despite the strengths of prospective design and use of objective outcome measures, this study is not without limitations. Firstly, the follow-up period of six months may be insufficient to capture long-term recurrence trends, particularly post-intervention. Secondly, the study was conducted at a single tertiary care center, limiting generalizability. Finally, socioeconomic and psychosocial factors influencing treatment compliance were not deeply explored.

This prospective study underscores the significant association between CEAP clinical classification and the severity of varicose vein disease, as measured by validated clinical scores and treatment outcomes. Patients in higher CEAP classes (C5–C6) exhibited substantially elevated VCSS and AVVQ scores, prolonged ulcer healing durations, and higher recurrence rates, indicating greater clinical burden and resource utilization. Furthermore, a clear shift toward surgical or laser interventions in advanced stages highlights the importance of early diagnosis and tailored management strategies. The study reinforces CEAP as a reliable, stage-based framework for prognostication, therapeutic planning, and outcome monitoring in chronic venous disorders. Its integration into routine clinical practice may enhance risk stratification and improve patient outcomes through timely intervention and targeted therapy.

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