Citation Nr: 21028965 Decision Date: 05/12/21 Archive Date: 05/12/21 DOCKET NO. 17-61 268 DATE: May 12, 2021 ORDER Entitlement to compensation under 38 U.S.C. 1151 for plugged right subclavian vein with stents is denied. FINDING OF FACT The Veteran does not have additional plugged right subclavian vein with stents that resulted from an event not reasonably foreseeable or any carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA. CONCLUSION OF LAW The criteria for compensation pursuant to 38 U.S.C. § 1151 for plugged right subclavian vein with stents are not met. 38 U.S.C. § 1151 (2018); 38 C.F.R. § 3.361 (2020). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from October 1988 to October 1992 and from February 1995 to April 1999. This matter comes to the Board of Veterans' Appeals (Board) on appeal from an August 2016 rating decision of a Department of Veterans Affairs (VA) Regional Office. The Veteran asserts via his written statements that he suffered complications following a procedure to stent his veins following a shattered right clavicle. He essentially contends that he developed blood restriction in his right shoulder following a clavicle reconstruction surgery which required a complicated surgical procedure to stent his veins which should have been performed at the Mayo Clinic. Instead the procedure was performed at a VA Medical Center (VAMC) and he developed complications following the procedure. Specifically, he reported that the surgery was unsuccessful, and VA had to perform a second procedure to open the plugged stents. VA was unable to perform the second procedure due to a bedbug infestation and he was referred to Abbott Northwestern for a second procedure to stent his veins. The Veteran indicated that the surgeon at Abbott Northwestern Hospital advised him that VA never should have tried to perform the first procedure to stent his veins. The Veteran was subsequently approved for care at the Mayo Clinic where it was determined that a vein bypass was not recommended as there was only a 10 percent chance the vein bypass would be successful. In July 2016, a VA surgeon reviewed the Veteran's claims file and recounted his complicated medical and surgical history. The clinician noted that the Veteran fell off a horse and suffered a fractured right clavicle in May 2010 and underwent an open reduction internal fixation (ORIF) and bone graft at the Fargo VAMC. In February 2011, he was noted to have right clavicle malunion and underwent hardware removal at the Omaha VAMC. His hospitalization was complicated by a deep vein thrombosis (DVT) of the right upper extremity. Anticoagulation treatment was recommended for six months but the Veteran tested positive for lupus anticoagulant and had marked variations in INRs (international normalized ratios). The Veteran apparently underwent a repeat surgery with clavicular plate replacement in April 2011 and removal of loose locking screw in April 2011. In mid-February 2015, the Veteran underwent a right upper extremity venogram and attempted recanalization of the right axillary and subclavian veins at the Fargo VAMC. The impression was occlusion of the proximal right cephalic vein and long term chronic occlusion of the right axillary and subclavian veins with collateral compensation to the chest wall and neck collaterals. The clinician was unable to recanalize chronically occluded central venous occlusion. A plan was made to wait six months to monitor the Veteran's condition. However, the Veteran contacted the VA clinician's office multiple times because he did not wish to wait an additional six months. He reported right-sided biceps pain and aching during the night and more prominent veins on the right chest in early March 2015 and requested a referral for his obstruction. The VA clinician advised the Veteran that there were no further referrals or any other interventions available. In mid-March 2015, the Veteran underwent a computed tomography angiography (CTA) at the Fargo VAMC which demonstrated occlusion of the right subclavian vein as well as probably the axillary vein with multiple collaterals over the right chest and upper extremity. The Veteran was advised that given the length of time of occlusion as well as CT findings, recanalization was not likely to be successful; however, the Veteran very much wished to pursue treatment. The clinician advised the Veteran that his numbness over the right upper shoulder and chest were not likely related to his veins and were more likely musculoskeletal in nature. The Veteran was informed that there was very good collateral flow draining from the right arm and that no further intervention was indicated. Conservative treatment and the use of anti-inflammatories was recommended with possible consideration of anticoagulation in the future with possibility of an agent other than Coumadin due to difficulties with his INR fluctuating widely with Coumadin use. In June 2015, a VA vascular surgeon at the Minneapolis VAMC discussed treatment options including compression garments, attempt at repeat venogram and recanalization, or open bypass. Later in June 2015, the Veteran underwent recanalization and stenting of the right subclavian/axillary veins. The procedure narrative indicated that venoplasty was performed with significant recoil restenosis and preferential flow through collaterals. The Veteran was placed on Warfarin with Enoxaparin bridging for three months. In July 2015, venous duplex performed at the Fargo VAMC showed thrombosis and occlusion of the right brachial/axillary/subclavian veins. The Veteran was referred to Minneapolis VA vascular surgery for repeat venogram and thrombolysis in 24-72 hours. He reported that his symptoms were worse than before intervention in June 2015. Rather than waiting, on the same day in July 2015, the Veteran presented at the Minneapolis VAMC for repeat venogram and thrombolysis. No beds were available, and he was referred to Abbott Northwestern Hospital. Several days later in July 2015, the Veteran underwent a right upper extremity venogram with infusion catheter-directed thrombolysis. A stent was placed; however, the vein ruptured and quickly thrombosed. Warfarin was resumed and Lovenox was ordered. In August 2015, the Veteran was seen at the Mayo Clinic where a vascular surgeon advised smoking cessation, formal rigorous compression garment trial for right upper extremity, and continuation with anticoagulation therapy with Coumadin. The Veteran was advised that surgery for right axilla venous occlusion would be a fairly extensive operation and would involve harvesting vein from his leg which carries significant morbidity. Additionally, the patency of the venous graft could be severely compromised if he continued to smoke in a hypercoagulable state. Two days later in August 2015, a clinician at the musculoskeletal clinic at the Mayo Clinic found that the Veteran had subclavian stenosis with stenting and likely had multiple causes for his pain, but his vascular abnormalities were the cause of the majority of his symptoms. He was advised to continue with indefinite anticoagulation for right subclavian vein obstruction/occlusion. In January 2016, the Veteran was seen by a vascular surgeon and a vascular physician at the Mayo Clinic. A duplex of the right upper extremity confirmed thrombosis of the right axillary and subclavian veins. The clinicians noted that the challenge for open operative venous bypass is difficult because of the length of vein segment which has to be bridged and because of the adequacy of inflow. For those reasons, the clinicians noted that it was not surprising that the recanalizations performed at the VA Hospital and Abbott Northwestern Hospital both failed. Following a discussion of the risks and complexity of another procedure and likelihood of failure, the clinicians indicated that their recommendation was for the Veteran to cease pursuing any further surgical intervention. The July 2016 VA clinician reviewed the Veteran's relevant medical records from both VA and the private hospitals where he was treated as well as the claims file and opined that the Veteran's right upper extremity symptoms of pain and swelling are less likely than not caused by the placement of stents in the right subclavian and axillary veins. The examiner noted that long segment occlusion of the right subclavian and axillary veins was documented in February 2015 and were essentially unchanged following failed angioplasty/stent treatments of said veins. The Veteran's symptoms of pain, swelling, and fatigue of the right upper extremity as well as weakness and paresthesias of the right chest wall were present prior to any angioplasty/stent treatment of the right subclavian/axillary veins. Additionally, the Veteran was advised by a VA interventional radiologist at the Fargo VAMC in February 2015 that he should not pursue endovascular treatment for the long segment, chronic occlusion of the right subclavian/axillary veins because said interventions would likely not remain patent or be successful. The clinician noted that while stent placement in the subclavian and axillary veins is controversial, there is no evidence of negligence or malpractice in the treatment provided to the Veteran by the Minneapolis VAMC. An attempt at recanalization of the occluded right subclavian and axillary veins was made to provide symptom relief to the Veteran. The VA clinician successfully recanalized the occluded vein segment and performed an angioplasty with significant recoil. One stent was not enough to restore flow and two additional stents were placed. The examiner noted that there is little literature regarding stent placement in the subclavian and axillary veins but there are successful, long term results of stenting in the subclavian vein for Paget-Schroetter syndrome and the treatment of hemodialysis-related central venous stenosis or occlusion. The examiner stated that careful and thorough research of the all of the Veteran's records show that the Veteran received the highest quality medical care at each institution where he underwent treatment including at the Minneapolis VAMC. The examiner concluded that there is no evidence of carelessness, negligence, error in judgment, or errors in medical or surgical treatment. In September 2017, an informal conference was held with the Veteran, his representative, and a Decision Review Officer (DRO) at the RO. The Veteran's representative submitted a medical treatise article entitled, "Comprehensive Management of Subclavian Vein Effort Thrombosis (also known as Pagett-Schroetter syndrome)." The article refers to the pathophysiology and optimal initial management of subclavian vein effort thrombosis and the indications, timing, and approaches used for the surgical treatment of venous thoracic outlet syndrome. The Veteran's representative claimed that the VA opinion was inadequate. The Board finds that the July 2016 VA medical opinion is adequate because the examiner thoroughly reviewed the claims file and discussed the relevant evidence, considered the contentions of the Veteran, and provided a thorough supporting rationale for the conclusions reached. Barr v. Nicholson, 21 Vet. App. 303 (2007); Stefl v. Nicholson, 21 Vet. App. 120 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Further, there is no medical opinion of record to the contrary. As such, the July 2016 medical opinion is the most probative evidence of record. The Board acknowledges that the Veteran submitted several lay statements and medical treatise evidence in support of his claim. While laypersons are competent to report observable symptoms, the Veteran is not competent to provide an opinion linking his claimed right upper extremity complications to the surgical procedure performed at VA. An opinion of that nature would require medical knowledge, training, and expertise and is simply outside the realm of common knowledge of a lay person. Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Therefore, the Veteran is not competent to provide an etiology opinion in this case. Moreover, the treatise evidence refers to the treatment for Pagett-Schroetter syndrome, which is not a condition for which the Veteran has received treatment. Consequently, the medical treatise evidence is of no probative value. Accordingly, the Board finds that the preponderance of the evidence is against the claim and entitlement to compensation pursuant to 38 U.S.C. § 1151 for plugged right subclavian vein with stents is not warranted. 38 U.S.C. § 5107(b) (2018); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Kristin Haddock Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Cryan, 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.