Citation Nr: 21030822 Decision Date: 05/19/21 Archive Date: 05/19/21 DOCKET NO. 16-35 978A DATE: May 19, 2021 ORDER Service connection for cause of the Veteran's death is granted. FINDING OF FACT The Veteran's ruptured abdominal aortic aneurysm which caused his death was attributable to an injury during his inactive duty training (INACDUTRA). CONCLUSION OF LAW The criteria for service connection for cause of the Veteran's death have been met. 38 U.S.C. §§ 101, 1131, 1310, 5107; 38 C.F.R. §§ 3.6, 3.102, 3.303, 3.312. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty for training (ACDUTRA) from October 1959 to April 1960 with additional service in the California Army National Guard. He died in March 1990. The appellant is his surviving spouse. The case is on appeal from an April 2016 rating decision. In February 2017, the Veteran testified at a Board hearing. Most recently, in September 2019, the Board denied the claim. The appellant appealed the denial to the United States Court of Appeals for Veterans Claims (Court). In a July 2020 Order, the Court granted the parties' July 2020 Joint Motion for Partial Remand (JMR) in which the parties requested that the Court vacate the September 2019 denial and remand the claim to the Board. Service connection for cause of the Veteran's death. Legal Criteria To establish service connection for the cause of the Veteran's death, the evidence must show that a service-connected disability was either the principal cause or a contributory cause of death. For a service-connected disability to be the principal (primary) cause of death, it must singly or with some other condition be the immediate or underlying cause of death or be etiologically related. For a service-connected disability to constitute a contributory cause, it must contribute substantially or materially; it is not sufficient to show that it casually shared in producing death, but rather it must be shown that there was a causal connection. 38 U.S.C. § 1310; 38 C.F.R. § 3.312. Active service includes periods of active duty for training (ACDUTRA) in which the individual concerned was disabled or died from a disease or injury incurred or aggravated in line of duty, and any period of inactive duty training (INACDUTRA) during which the individual concerned was disabled or died from an injury incurred or aggravated in line of duty or from an acute myocardial infarction, a cardiac arrest, or a cerebrovascular accident which occurred during such training. 38 C.F.R. § 3.6(a). Facts As noted above, the Veteran died in March 1990 from a ruptured abdominal aortic aneurysm, as well as multiple-organ system failure, shock and hypertension. The appellant contends the Veteran was injured during a period of INACDUTRA which subsequently led to his death. Alternatively, she asserts the Veteran had an acute myocardial infarction, a cardiac arrest, or a cerebrovascular accident during a period of INACDUTRA. She indicates in the February 2017 Board hearing that, in March 1990, the Veteran left home for his weekend drill duty and then fell ill and was hospitalized. After 16 days in the hospital, the Veteran died from a ruptured abdominal aortic aneurysm, along with the other issues noted above. The Board notes the Veteran had no service-connected disabilities during his lifetime. Thus, the pertinent question is whether the Veteran's death was the result of an injury during his INACDUTRA, progressive atherosclerotic deterioration in the aortic wall (disease) or one of the following diseases: acute myocardial infarction, cardiac arrest, or cerebrovascular accident. Consistent with the appellant's testimony, the record reflects that during a period of INACDUTRA, the Veteran reported feeling ill the morning of March 4, 1990. He was told by his section sergeant to report to the orderly room for sick call. Military personnel records show the Veteran stopped in the men's latrine on the way and was found there approximately three hours later. He was then transported to the hospital and remained there from March 4, 1990, to March 20, 1990, his date of death. He suffered a ruptured abdominal aortic aneurysm and underwent four operations, including an abdominal aortic aneurysmectomy. The Board determined an expert medical opinion was needed from the Veterans Health Administration (VHA). A January 2018 medical opinion was authored by Dr. Curci, a chief vascular and endovascular surgeon at a VA Medical Center. He opined the Veteran's abdominal aortic aneurysm and rupture was not the result of an injury and was not related to acute myocardial infarction, cardiac arrest or cerebrovascular accident. He reported abdominal aortic aneurysms that rupture result from a chronic degenerative process within the wall of the blood vessels. He stated aneurysmal degeneration affects all three principal layers of the wall of the aorta. This process is distinct from atherosclerotic disease processes which only affect the innermost layer of the blood vessel wall. He indicated there is often concomitant atherosclerotic disease present in the aorta, as well as other vessels in patients with infrarenal abdominal aortic aneurysms. The reviewer stated aneurysmal degenerative processes must be active for years before the degeneration is so severe as to result in rupture and the Veteran's cause of death was the rupture of his infrarenal aortic aneurysm. The physician noted rupture of these vessels occurs when mechanical forces of blood flow and pressure exceed the strength of the degenerative wall. He opined according to the presentation of lower abdominal pain found in the Veteran's medical records, the aneurysm which led to his death had ruptured at least 48 hours prior to presentation. Dr. Curci additionally opined abdominal aortic aneurysms do not occur due to injury. He stated rupture of such aneurysms nearly always occurs as a result of blood pressure exceeding the strength of the weakened wall of the aorta. He indicated direct traumatic injury to the aorta can occur only in exceptional cases due to the location of the aorta in the body. The reviewer stated, "There is no evidence that an aortic injury occurred in this Veteran, and thus neither the aneurysm nor the rupture can be attributed to injury." He further opined aortic aneurysms and the rupture of an aortic aneurysm does not occur as the result of acute myocardial infarction, cardiac arrest or cerebrovascular accident. In December 2018, the Board sent the appellant a letter informing her of the VHA opinion and allowing for 60 days to submit additional evidence and argument. In January 2019, the appellant submitted additional lay evidence and specifically indicated that she did not waive RO consideration of the evidence and requested that the case be remanded to the RO for consideration of the new evidence in the first instance. See 38 C.F.R. § 19.31. In a January 2019 statement, the appellant indicated due to the Veteran's medical condition, he was not able to leave the premises when he fell ill which prevented him from seeking proper medical attention and resulted in his death. Based on the appellant's request, the Board remanded the claim for RO consideration in March 2019. Thereafter, the RO readjudicated the claim and issued a May 2019 supplemental statement of the case (SSOC). As noted above, the claim was denied by the Board in September 2019 and in July 2020, the Court granted a JMR which vacated the denial and remanded the issue back to the Board. Thereafter, a medical opinion dated November 2019 was submitted in support of the claim from Dr. Golden, a physician Board certified in internal medicine and fellowship trained in adult cardiovascular disease. He indicated after review of the Veteran's medical records, his abdominal aortic aneurysm rupture which caused his death was related to the stress of his job with the National Guard on the day he went to the hospital. Dr. Golden stated at the time of the Veteran's death in 1990, he was the Veteran's primary care physician. He noted he was also present in the emergency room when the Veteran was brought to the hospital from his National Guard Unit Training Center. He opined during the time of the Veteran's National Guard duty when he suffered an aortic aneurysm, he was under significant stress because his unit was being prepared to be activated for transfer to the Gulf War. In the November 2019 opinion, Dr. Golden took note of the January 2018 medical opinion from Dr. Curci, including that an aortic aneurysm is not an acute event and rupture of the vessels occurs when mechanical forces of blood flow and pressure exceed the strength of the degenerated vascular wall. However, Dr. Golden disagrees with these conclusions and stated, "it is my opinion that the stress of his job with the National Guard on that day led to an abdominal aortic aneurysm rupture." He further indicated on the day when the rupture occurred, the Veteran knew about a pending activation with transfer to the Gulf War. He noted there is a high likelihood that these circumstances increased the Veteran's blood pressure leading to increased intra-aortic wall tension beyond the point which exceeded the tensile strength of the abdominal aortic wall. Thus, he stated, this significant increase in stress led to the Veteran's aortic aneurysm rupture. Analysis After a review of the evidence both for and against the appellant's claim, the Board determines service connection for the cause of the Veteran's death is warranted. The Board finds the evidence has reached a level of equipoise as to whether the Veteran suffered an injury in March 1990 during a period of INACDUTRA and that the injury led to his ruptured abdominal aortic aneurysm which caused his death. 38 C.F.R. § 3.102. As noted, the January 2018 medical opinion from Dr. Curci was against the claim and the November 2019 opinion from Dr. Golden was in favor of the claim. The January 2018 medical report indicated the Veteran's abdominal aortic aneurysm and rupture was not the result of an injury and was also not related to acute myocardial infarction, cardiac arrest or cerebrovascular accident. He reported abdominal aortic aneurysms that rupture result from a chronic degenerative process within the wall of the blood vessels and rupture of these vessels occurs when blood flow and pressure exceed the strength of the degenerative wall. In contrast, the November 2019 examiner opined the Veteran's abdominal aortic aneurysm rupture was related to the stress of his job with the National Guard on the day he went to the hospital in March 1990. Dr. Golden is a physician Board certified in internal medicine and trained in adult cardiovascular disease. Further, at the time of the Veteran's death in 1990, he was the Veteran's primary care physician and was present in the emergency room when the Veteran was brought to the hospital, prior to his death. This gives Dr. Golden the necessary experience, perspective and ability to opine as to the Veteran's medical condition prior to and leading up to his death. Dr. Golden indicated when he suffered an aortic aneurysm and rupture, he was under significant stress because his unit was being prepared to be activated for transfer to the Gulf War. Dr. Golden stated this significantly increased the Veteran's blood pressure leading to increased intra-aortic wall tension and a rupture. The Board determines both medical opinions discussed are thorough and highly persuasive as to the Veteran's cause of death. Therefore, the Board finds the evidence has reached a level of equipoise. In sum, the Board finds the Veteran's cause of death was a result of an injury suffered during his period of INACDUTRA which led to his death. Thus, when resolving reasonable doubt in the appellant's favor, the Board determines service connection for the cause of the Veteran's death is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. RYAN T. KESSEL Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Isaacs, Brandon 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.