Citation Nr: 21069933 Decision Date: 11/22/21 Archive Date: 11/22/21 DOCKET NO. 15-42 596 DATE: November 22, 2021 ORDER Entitlement to service connection for a left carotid artery aneurysm, to include as secondary to service-connected left and right hip disabilities, is denied. FINDING OF FACT A left carotid artery aneurysm was not manifested during the Veteran's active service, and is not shown to be etiologically related to his service or to have been caused or aggravated by his service-connected bilateral hip disability (and treatment for such). CONCLUSION OF LAW Service connection for left carotid artery aneurysm, to include as secondary to service-connected bilateral hip disabilities, is not warranted. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The appellant is a Veteran who served on active duty from February to June 1969. This matter is before the Board of Veterans' Appeals (the Board) on appeal from a June 2012 rating decision. In August 2016, a Travel Board hearing was held before the undersigned; a transcript is in the record. In August 2018, the Board dismissed a claim of service connection for a brain aneurysm, declined to reopen a claim of service connection for a left knee disability, and denied service connection for a bilateral hip disability. The Veteran appealed the August 2018 Board decision to the U.S. Court of Appeals for Veterans Claims (CAVC). A November 2019 CAVC Memorandum Decision vacated the Board's decision and remanded the matters seeking to reopen a claim of service connection for a left knee disability, and entitlement to service connection for a bilateral hip disability and a brain aneurysm for further development and readjudication. [The CAVC specifically found that the Board erred in dismissing the claim of service connection for a brain aneurysm because it made no findings regarding whether the Veteran understood the consequences of oral and written statements asking the claim to be withdrawn.] In a May 2020 statement, the Veteran clarified that the claim of service connection for a brain aneurysm should actually be a claim for a left carotid artery (neck) aneurysm; the characterization of the issue was therefore revised in a July 2020 Board decision. The July 2020 Board decision reopened the claim of service connection for a left knee disability, and remanded that claim on de novo review, along with the matters of service connection for a bilateral hip disability and a left carotid artery aneurysm, for additional development. An interim (November 2020) rating decision, in relevant part, granted service connection for left knee, right hip, and left hip disabilities. Accordingly, those matters are no longer before the Board. In July 2021, the instant matter was again remanded for additional development. Entitlement to service connection for left carotid artery aneurysm, to include as secondary to service-connected left and right hip disabilities, is denied. Legal Criteria Service connection may be granted for disability due to disease or injury incurred in or aggravated by active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Service connection may be granted for a disease initially diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To substantiate a claim of service connection, there must be evidence of: (1) a current claimed disability; (2) incurrence or aggravation of a disease or injury in service; and (3) a nexus between the current disability and the disease or injury in service. See Shedden v. Principi, 281 F.3d 1163, 1166-67 (Fed. Cir. 2004). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and an evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a). Secondary service connection may be established for a disability that is proximately due to, or the result of, or aggravated by a service-connected disease or injury. Establishing secondary service connection requires evidence of: (1) a current disability (for which secondary service connection is sought); (2) an already service-connected disability; and (3) that the claimed disability was either caused or aggravated by the already service-connected disability. 38 C.F.R. § 3.310(a); see also Allen v. Brown, 7 Vet. App. 439 (1995). Lay evidence may be competent evidence to establish incurrence. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). However, competent medical evidence is necessary where the determinative question is one requiring medical knowledge. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Factual Background The Veteran contends that his left carotid artery aneurysm was caused by (is a complication of) the multiple hip surgeries he underwent in 2011. See May 2020 statement. The Veteran's service treatment records (STRs) do not show complaints, treatment, or diagnosis of carotid artery aneurysm. On May 1969 service separation examination, his vascular system was normal on clinical evaluation. On June 1970 VA examination (in connection with a left knee claim), the Veteran reported left knee and right fourth finger disabilities. He did not report a carotid artery aneurysm. His cardiovascular system was normal on clinical evaluation. On April 1997 VA general medical examination, the Veteran did not report a carotid artery aneurysm, and such was not diagnosed. His cardiovascular system was normal on clinical evaluation. Postservice VA treatment records prior to August 2011 consistently note that there was no carotid bruit on physical examination. See VA treatment records dated July 1999, October 2001, January 2002, March 2003, February 2004, February 2005, November 2008, and March 2011. An August 2011 VA treatment record notes the Veteran was seen for evaluation of a 3.1 x 2.5 mm left intracavernous aneurysm "accidentally found pre-op [emphasis added] eval hip surgery this year." His neurologic system was "intact, no drift." His motor system was normal, and he had symmetric muscle bulk and tone in all limbs. No tremor or abnormal movements were observed. The diagnosis was left cavernous internal carotid artery (ICA) aneurysm. No treatment or follow up was deemed necessary. A separate treatment record from the same date notes an assessment of "incidental intracavernous aneurysm." A subsequent August 2011 VA treatment record notes the Veteran's report that, following a June 2011 hip surgery, he slipped and broke his left hip going down a ramp. He did not remember slipping, and "must've passed out." He reported that doctors found the aneurysm after that event. At his August 2016 Board hearing, the Veteran testified that doctors "found something...when I had broke my hips and they said they thought that might have been what made me blackout the second time I fell and re-broke my hip because I had four hip surgeries in one year." In a May 2020 statement, the Veteran reported that he has CAT scans every six months to check the status of his left carotid artery aneurysm. He also reported that VA doctors informed him that the aneurysm was caused by four hip surgeries. In July 2020, pursuant to the CAVC Memorandum decision the Board noted this matter was intertwined with the claim of service connection for a bilateral hip disability and remanded the instant claim for development to ascertain the likely etiology of the left carotid artery aneurysm, to specifically include whether it at least as likely as not was caused or aggravated by the service-connected hip disabilities (to include the surgical treatment for such, i.e., whether his left carotid artery aneurysm was caused by/a complication of such treatment). On April 2021 VA (fee basis) artery and vein conditions examination, left cavernous ICA aneurysm was diagnosed. The Veteran reported that he has no current symptoms, but is followed by a VA physician for continued monitoring every 6 12 months. Surgical intervention has not been required. He reported that in 2011, after his third and fourth hip surgeries, he experienced orthostatic hypotension, including dizziness and light-headedness, when he rose from bed. Following interview/examination of the Veteran and review of his record, the examiner checked the appropriate box to opine that the Veteran's left cavernous ICA aneurysm is less likely than not related to his service. She explained, with citation to treatment records, that such was an "incidental finding preoperatively in preparation of hip surgery." She wrote that "there is no causal relationship to the the (sic) Veteran's musculoskeletal conditions or surgical procedures." She explained that risk factors for ICA aneurysm include hypertension, smoking, family history, and connective tissue disorders. She noted that the Veteran has hypertension and a history of smoking, and therefore opined that the likely etiology of the aneurysm "is likely secondary to hypertension and smoking." The opinion did not address whether the Veteran's left carotid artery aneurysm has been aggravated by his service-connected hip disabilities, including the surgical treatment for such. In August 2021, a different VA (fee basis) physician reviewed the record and opined that the Veteran's left carotid artery aneurysm was less likely than not caused or aggravated by his service-connected hip disabilities, to specifically include treatment (including surgery) for such. He wrote, "There is no pathoanatomical correlation for causality, aggravation, or a complication from between hip issues to include surgery and the carotid artery aneurysm. Hypertension, smoking, hypercholesterolemia are the known and accepted causes or arterial aneurysms. Hip pathology and/or surgery or complications from hip surgery will not lea[d] to an aneurysm. Based on the lack of pathoanatomical correlation there is no nexus in this case." He noted that the aneurysm was "incidentally found"; he also noted that it was asymptomatic prior to its discovery and that the current severity is not greater than the baseline severity. Analysis The Veteran's primary theory of entitlement to the benefit sought is one of secondary service connection; he contends that his left carotid artery aneurysm was caused by (or is a complication of) his service-connected hip disabilities (and the treatment for such). It is not in dispute that he has a diagnosis of left cavernous ICA aneurysm, as such has been noted in treatment records and was noted on April 2021 VA (fee basis) artery and vein conditions examination. The Veteran's left cavernous ICA aneurysm was not noted in service, and was not clinically noted prior to 2011, four decades after his separation from service. Accordingly, service connection for such disability on the basis that it became manifest in service and persisted is not warranted. The Board has considered whether the Veteran's left cavernous ICA aneurysm may otherwise (on a direct basis) be etiologically related to the his active duty service. His STRs are silent for left cavernous ICA aneurysm complaints, treatment, or diagnosis, and his vascular system was clinically normal on May 1969 service separation examination. Left cavernous ICA aneurysm is not shown to have been manifested for four decades after separation from service, and contemporaneous examinations and treatment records during that interim period do not show complaints, or a finding, of left cavernous ICA aneurysm. Notably, the Veteran does not contend that it was manifested in service and has continued since. There is no competent (medical opinion) evidence that relates his left cavernous ICA aneurysm to his active duty service; he has not submitted any such evidence. The only competent medical opinion evidence in the record regarding the etiology of the left cavernous ICA aneurysm (on a direct basis) is in the April 2021 VA examiner's opinion that such disability was not due to or caused by service. 38 C.F.R. § 3.303(d). There is no competent (medical opinion/treatise) evidence to the contrary, and the Board finds the April 2021 VA examiner's opinion to be persuasive. The analysis turns to the Veteran's asserted primary theory of entitlement, that of secondary service connection. The Board notes the Veteran's own assertion that his left cavernous ICA aneurysm was caused or aggravated by his bilateral hip disability (and surgical treatment for such). However, the etiology of a carotid artery aneurysm first diagnosed more than four decades after separation from service (and, here, alleged on a secondary basis) is a medical question. See Jandreau v. Nicholson, 492 F.3d at 1377. As he is a layperson, the Veteran lacks the requisite expertise to offer a probative opinion relating his left cavernous ICA aneurysm to his bilateral hip disability. He has not submitted any medical opinion or medical literature in support of his claim. To the extent he reports a doctor told him the aneurysm was caused by four hip surgeries, the CAVC has held that a layman's account of what a physician purportedly said, filtered through a layman's sensibilities, is simply too attenuated and inherently unreliable to constitute "medical" evidence. See Robinette v. Brown, 8 Vet. App. 69, 77 (1995); also see Jandreau v. Nicholson, 492 F. 3d 1372, 1377 (Fed. Cir. 2007). The Board finds the most probative evidence pertaining to the secondary service connection theory of entitlement to be the August 2021 opinion, in conjunction with the April 2021 opinion, which both note that the providers reviewed the record and considered the Veteran's lay assertions (including the Board hearing transcript and the prior (July 2021) Board remand). The August 2021 consulting provider specifically explained that there is no pathoanatomical correlation for causality, aggravation, or a complication between hip issues (to include surgery for such) and a carotid artery aneurysm. And the April 2021 provider explained that the more likely etiology is the Veteran's hypertension and past history of smoking. The providers, medical professionals with medical training and experience, supported the detailed opinions offered with rationale that cites to relevant factual data and medical principles. The Veteran's lay statements and recollections of what he may have been told are far outweighed by the medical opinions provided by the medical professionals (both the April and August 2021 providers) who reviewed relevant evidence specific to the Veteran. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Considering the foregoing, the Board finds that the preponderance of the evidence is against this claim. Therefore, the benefit of the doubt rule does not apply; the appeal in the matter must be denied. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). GEORGE R. SENYK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Dupont, Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.