Citation Nr: 21016206 Decision Date: 03/22/21 Archive Date: 03/22/21 DOCKET NO. 20-03 971 DATE: March 22, 2021 ORDER Entitlement to service connection for peripheral vascular disease of the right lower extremity, to include as secondary to service-connected coronary artery disease is denied. FINDING OF FACT The preponderance of the evidence is against a finding that the Veteran’s diagnosed peripheral vascular disease of the right lower extremity was either caused by or incurred in service, or was caused or aggravated by a service-connected disability, to include coronary artery disease. CONCLUSION OF LAW The criteria for entitlement to service connection for peripheral vascular disease of the right lower extremity, to include as secondary to service-connected coronary artery disease have not been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. § 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Army from March 1966 to March 1969. This case comes on appeal of an April 2014 rating decision. This matter was previously before the Board in August 2020. At that time, the Board remanded the claim to ensure that VA had fulfilled its duty to assist by helping the Veteran obtain private treatment records relevant to his claim. Subsequent to the Board’s remand, the agency of original jurisdiction (AOJ) made two requests for the Veteran to submit a VA Form 21-4142 to allow VA to obtain his private records, however, the Veteran did not respond to those requests. The Board considers the AOJ to have substantially complied with the Board’s remand instructions. Entitlement to service connection for peripheral vascular disease of the right lower extremity, to include as secondary to service-connected coronary artery disease Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303, 3.304. Service connection generally requires evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Walker v. Shinseki, 701 F.3d 1331 (Fed. Cir. 2013). Moreover, disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected as well. Notwithstanding the lack of evidence of disease or injury during service, service connection may still be granted if all of the evidence, including that pertinent to service, establishes that the disability was incurred in service. See 38 U.S.C. § 1113(b); 38 C.F.R. § 3.303(d). The record demonstrates that the Veteran has a currently diagnosed peripheral vascular disease disability. Therefore, the, first requirement of service connection has been satisfied. At issue is whether the disability is causally related to service. In this regard, there is nothing to suggest that peripheral vascular disease was directly caused by service, nor that it had an in-service onset. Although treatment records associated with the claims file are fairly sparse, service treatment records do not demonstrate that the Veteran had any vascular conditions during service. VA treatment records demonstrate that, during the course of a January 2009 evaluation for coronary artery disease, the Veteran was not shown to have peripheral vascular disease. Thus, the evidence suggests that peripheral vascular disease had its onset well after service. Moreover, the Veteran has not suggested that any in-service experience or event caused peripheral vascular disease. Instead, the Veteran’s primary contention is that peripheral vascular disease was caused by surgery he underwent to treat service-connected coronary artery disease. In July 2014 the Veteran submitted a disability benefits questionnaire (DBQ) provided by C.J.N., the Veteran’s medical provider. C.J.N. reported that the Veteran first underwent coronary artery bypass grafts in 1998, and then had additional coronary artery bypass grafts in January 2009 to retreat two of the five prior grafts. In the July 2014 DBQ, C.J.N. reported that the coronary artery bypass grafts were performed using saphenous vein harvested from the Veteran’s right lower extremity. Since that time, the Veteran had reported intermittent coldness and pains in the right lower extremity, and that minor injuries to the right lower extremity took longer to heal than did injuries to the left lower extremity. Notably, C.J.N. did not provide a medical opinion specifically attributing the Veteran’s peripheral vascular disease to the coronary artery bypass grafts surgeries. Given that the Veteran’s diagnosis and contentions were clear, in December 2019, VA obtained a medical opinion regarding the etiology of peripheral vascular disease. At that time, the examiner opined that the Veteran’s peripheral vascular disease was less likely than not proximately due to the Veteran’s service-connected coronary artery disease. By way of rationale, the examiner explained that there has been no notation of any venous involvement related to the PVD found in the record. The examiner went on to explain, “Although the Veteran reports that his symptoms coincided with his bypass surgery, the vein graft extraction would not have affected his arterial blood flow from an anatomic and physiologic perspective. Physiologically, the venous flow is far distal to the arterial flow, and extraction of a superficial vein graft does not affect the arterial flow which is long before the blood flow reaches the vascular system. This Veteran’s occlusions are far proximal to the distal vein graft anatomically as well as deeper in the tissue.” The examiner further stated that there was no documentation of any injury to any artery during the coronary artery bypass graft procedure found in the record that would have affected the Veteran’s right femoral artery. Post-operation, there were no indications of injury or occlusions and the Veteran’s distal pulses were noted as normal. The examiner also explained, “The Veteran’s peripheral arterial disease is atherosclerotic on the imaging. That means that the reason for the occlusions were atherosclerotic disease. Although the Veteran’s [coronary artery disease] is also atherosclerotic disease, [coronary artery disease] does not cause atherosclerotic disease elsewhere. The causes of both conditions are related to underlying risk factors primarily of aging and tobacco use.” Here, the examiner found that the Veteran’s primary risk factors for the development of peripheral vascular disease were aging with a history of tobacco use, noting that the Veteran had a documented 20-year history of 1.5 packs per day of tobacco use. The Board finds the VA examiner’s opinion to be highly probative as it provides a thorough explanation as to why the Veteran’s peripheral vascular disease would not be causally related to the coronary artery bypass grafts, or to the Veteran’s coronary artery disease generally. The Board acknowledges that, in this opinion, the examiner did not explicitly state that peripheral vascular disease was not aggravated by the Veteran’s service-connected condition. Nevertheless, the examiner’s rationale included sufficient discussion as to why there was no etiological relationship between the two conditions whatsoever. Indeed, the examiner stated that the vein graft extraction utilized in the Veteran’s coronary artery bypass graft “would not have affected” the Veteran’s lower extremity arterial blood flow from an anatomic and physiologic perspective and that “there is no documentation of any injury to any artery during his [coronary artery bypass graft] procedure that would have affected the right femoral artery.” The examiner further explained that coronary artery disease and peripheral vascular disease are both atherosclerotic diseases; however, this does not imply any relationship between the two, other than that they have the same underlying risk factors—primarily aging and tobacco use. The Board finds that, although the examiner’s opinion did not explicitly state that peripheral vascular disease was not aggravated by the Veteran’s coronary artery disease and treatment thereof, the examiner’s language makes it clear that the examiner has contemplated theories of both causation and aggravation. In making this finding, the Board looks to the examiner’s use of the phrase “would not have affected” and the examiner’s assertion that there was no documentation of any injury that “would have affected” the right femoral artery. For the coronary artery disease and treatment to have aggravated the peripheral vascular disease, it inherently would have had to affect the condition. The examiner has explicitly ruled out such effects in this opinion. In making this finding, the Board agrees with the reasoning outlined by the Court in a non-precedential December 22, 2016 Memorandum Decision, Boecking-Rowell v. McDonald, 2016 U.S. App. Vet. Claims LEXIS 1971. In that decision, the presiding Judge found no error in the Board’s reliance on a prior examiner’s opinion indicating that the appellant’s left knee disability was “without any relationship to” the opposite knee injury/condition in the context of adjudicating a secondary service-connection claim. The presiding Judge noted that “[b]ecause the examiner clearly opined that there was no relationship whatsoever between the service-connected right knee disability and the left knee disability, this statement, unlike the examiner’s statement in El-Amin [v. Shinseki, 26 Vet. App. 136 (2013)], unquestionably rules out the possibility that the service-connected disability may aggravate to some degree the non-service-connected disability. See Bethea v. Derwinski, 2 Vet. App. 252, 254 (1992) (single judge decisions may be relied upon for any persuasiveness or reasoning they contain). The Board similarly finds that the opinion as stated by December 2019 examiner rules out the possibility that the service-connected coronary artery disease aggravates to some degree the non-service-connected peripheral vascular disease of the right lower extremity. Furthermore, the examiner provided a valid alternative etiology for the Veteran’s peripheral vascular disease disability. Additionally, the Board takes note that the examiner’s opinion was limited to review of the Veteran’s January 2009 coronary artery bypass grafts. As was discussed above, VA afforded the Veteran an opportunity to provide records of his 1998 surgery, but the Veteran did not respond to those efforts. In contrast, the only evidence of record suggesting a positive relationship between peripheral vascular disease and coronary artery disease is the July 2014 DBQ, and the Veteran’s own assertions regarding his symptoms. As was previously discussed, in the July 2014 DBQ, C.J.N. relayed the Veteran’s description of the timing of his symptoms, but did not go so far as to provide a medical opinion linking the Veteran’s peripheral vascular disease to the coronary artery bypass grafts. Additionally, although the Veteran is competent to describe his onset of symptoms, as a layperson he is not competent to provide an etiological opinion regarding those symptoms as such would require medical expertise. Barr v. Nicholson, 21 Vet. App. 303, 307-08 (2007). (Continued on Next Page) Thus, the preponderance of the evidence is against a finding that peripheral vascular disease was caused by or incurred in service, or was caused or aggravated by a service-connected disability. As the preponderance of the evidence is against these findings, the “benefit of the doubt” rule is not applicable and the Board must deny the claim. See 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). V. Chiappetta Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Giaquinto, 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.