Citation Nr: 21031491 Decision Date: 05/24/21 Archive Date: 05/24/21 DOCKET NO. 18-18 273 DATE: May 24, 2021 ORDER Service connection for peripheral vascular disease (PVD) is denied. REMANDED A compensable rating for hypertension is remanded. FINDING OF FACT PVD was not causally or etiologically related to service, was not continuous since service, was not shown to a compensable degree within one year of separation from service, was not shown for many years after service, and was not caused or permanently worsened by a service-connected disorder, to include hypertension. CONCLUSION OF LAW PVD was not incurred in service, may not be presumed to have been incurred in service, and was not proximately due to or aggravated by a service-connected disability. 38 U.S.C. §§ 1101, 1110, 1112, 5103(a) (2012); 38 C.F.R. §§ 3.102, 3.303(a), 3.307, 3.309, 3.310 (2020). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service from April 1969 to December 1971, to include service in the Republic of Vietnam. These matters come before the Board of Veterans' Appeals (Board) on appeal of a November 2015rating decision issued by the Department of Veterans' Affairs (VA) Regional Office (RO). As an initial matter, the Board remanded the claims on appeal for additional development in August 2020. In its remand, the Board characterized the claims on appeal, in relevant part, as entitlement to service connection for a bilateral eye disorder, claimed as PVD. However, the record fails to reflect a claim for a bilateral eye disorder. Rather, it is clear from the Veteran's April 2016 notice of disagreement that he is seeking entitlement to service connection for PVD. Therefore, the claim has been recharacterized accordingly and his case has now been returned to the Board for further appellate action. Turning to the relevant laws and regulations, service connection may be granted on a direct basis as a result of disease or injury incurred in service based on nexus using a three-element test: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred in or aggravated by service. See 38 C.F.R. §§ 3.303(a), (d); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). Service connection may be granted on a presumptive basis for diseases listed in § 3.309 under the following circumstances: (1) where a chronic disease or injury is shown in service and subsequent manifestations of the same disease or injury are shown at a later date unless clearly attributable to an intercurrent cause; or (2) where there is continuity of symptomatology since service; or (3) by showing that the disorder manifested itself to a degree of 10 percent or more within one year from the date of separation from service. See 38 C.F.R. § 3.307. Service connection may be granted on a secondary basis for a disability which is aggravated by, proximately due to, or the result of a service-connected disease or injury under 38 C.F.R. § 3.310. Allen v. Brown, 7 Vet. App. 439 (1995). In order to establish service connection on a secondary basis, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a link between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). As an initial matter, cardiovascular-renal diseases, such as PVD, are chronic disorders under 38 C.F.R. § 3.309(a); as such, presumptive service connection on the basis of continuity of symptomatology will be considered. Further, the Veteran has argued that his PVD is the product of his service connected hypertension; therefore, secondary service connection will also be addressed. Finally, direct service connection will be discussed. Turning first to direct service connection, the Veteran has been diagnosed with PVD. Specifically, an October 2015 VA examination diagnosed PVD and a prior June 2015 medical treatment note observed that he had a history of the disorder. Therefore, a current disorder has been shown and the first element of service connection has been met. A review of the service treatment records (STRs) shows that his vascular system was found to be clinically normal in his December 1971 separation examination. The STRs are otherwise silent for complaints, diagnoses, or treatment of PVD or any related disorder. During the December 1971 separation examination, evaluation of the heart and vascular system were normal. In a corresponding report of medical history, the Veteran specifically denied having had symptoms indicative of PVD. If present during service, the Board would expect the Veteran would have responded "yes" when asked if he had such symptoms at separation. The Board finds the report of medical history at separation from service to be highly probative as it was done contemporaneous to service and for the purpose of identifying disability at that time. As such, PVD was not noted in his STRs, an in-service incurrence has not been established, and the medical evidence does not support service connection on a direct basis. Turning to the one-year presumption, PVD did not manifest to a compensable degree within a year of separation from service. In a June 2010 imaging report, mild vascular calcification of the right knee was observed. In subsequent August 2015 and October 2015 VA examinations, the Veteran reported occasional weakness in his legs, particularly when he went to exercise classes, and said that the symptoms began in 2005. The October 2015 examiner ultimately diagnosed PVD. Even assuming that he developed symptoms of PVD as early as 2005, this is well outside the one-year legal presumption for certain chronic diseases such as PVD. Next, the record does not establish continuity of symptomatology under 38 C.F.R. § 3.309(a). As noted above, the evidence shows that the Veteran's symptoms began as early as 2005, 34 years after his separation from service. Therefore, PVD was not shown until 2005, with documentation beginning in 2010. In light of the above, the preponderance of the evidence is against the claim for service connection based on continuity of symptomatology and the appeal is denied on this basis as well. Turning to secondary service connection, the Veteran has been diagnosed with PVD and is service connected for hypertension. Therefore, a current disorder and a service-connected disability have been shown and the first two elements of secondary service connection have been met. However, the medical evidence does not support a nexus between the two. Specifically, in a June 2015 letter, a private clinician documented that the Veteran had multiple disorders, including PVD, that were all related to long-term hypertension. However, the clinician did not provide a rationale for the opinion. Further, the clinician failed to opine as to whether his PVD was caused or aggravated by his hypertension. Therefore, the June 2015 private medical opinion is assigned lesser probative value. In a subsequent October 2015 VA examination, the examiner opined that it was less likely than not that the Veteran's PVD was proximately due to or the result of his service-connected hypertension, explaining that PVD is an occlusive and inflammatory disease that develops within the peripheral arteries, veins, and lymphatics. The examiner detailed that the disorder referred to arterial pathologies that affect the vasculature outside of the heart and offered that medical literature and evidence-based medicine did not find that hypertension caused or was a risk factor for PVD. The examiner thoroughly reviewed the claims file and discussed the relevant evidence, to include whether a nexus existed between the Veteran's current PVD and his service connected hypertension, considered his assertions, and provided a thorough supporting rationale for the conclusion reached. As such, the October 2015 VA examination was adequate, and it is assigned high probative value. Most recently, in an April 2021 statement, the Veteran, through his attorney, suggested that there was a relationship between his heart disease, PVD, and hypertension. Citing a medical article which found that people with uncontrolled high blood pressure were more likely to have peripheral arterial disease and other heart problems, he offered that service connection for PVD as secondary to hypertension was plausible. However, while the Veteran is competent to report symptoms and describe observations because this requires only personal knowledge as it comes to him through his senses, he is not competent to opine as to the etiology of any disorder, to include PVD, due to the medical complexity of the issues involved. Therefore, the April 2021 statement is assigned lesser probative value and does not support a claim for secondary service connection. The medical record does not establish a relationship between the Veteran's PVD and a service-connected disability; accordingly, the medical evidence does not support the claim of service connection for PVD as secondary to hypertension. In sum, the medical evidence does not establish a nexus between his current PVD and either his active service or a service-connected disability, to include hypertension. Therefore, based on the above, the medical evidence weighs against the claim. The Board has considered the medical article cited by the Veteran concerning the relationship between hypertension and peripheral artery disease. However, the article cited does not address the Veteran's specific case or establish that his PVD was related either to his hypertension or directly to his active service. The Board has also considered lay statements submitted by the Veteran regarding the etiology of his PVD. As noted above, he is competent to report symptoms and describe observations because this requires only personal knowledge as it comes to him through his senses. However, he is not competent to offer opinions as to the etiology of any current disorder due to the medical complexity of the matters involved. Such competent medical evidence has been provided by the medical personnel who have examined the Veteran during the current appeal and by STRs and clinical records obtained and associated with the claims file. Here, the Board attaches greater probative weight to the clinical findings than to the lay statements that have been submitted. In reaching the above conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in this case. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND In an April 2021 statement, the Veteran, through his attorney, asserted that the severity of his hypertension had increased and that his symptoms were getting worse. A review of the record shows that he was last afforded an examination for his hypertension in August 2015. In light of the Veteran's assertion that his symptoms have worsened, a remand is necessary to afford him a new examination to determine the current level of severity of all impairments resulting from his hypertension. The matter is REMANDED for the following action: 1. Ask the Veteran to identify any outstanding treatment records relevant to his hypertension claim. All identified VA records should be added to the claims file. All other properly identified records should be obtained if the necessary authorization to obtain the records is provided by the Veteran. If any records are not available, or the Veteran identifies sources of treatment but does not provide authorization to obtain records, appropriate action should be taken (see 38 C.F.R. § 3.159(c)-(e)), to include notifying the Veteran of the unavailability of the records. 2. After records development is completed, schedule the Veteran for an examination to determine the current severity of all impairment resulting from his hypertension. The claims file should be made available to the examiner. All indicated tests and studies should be performed. The examiner should provide all information required for rating purposes. ROBERT N. SCARDUZIO Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Spigelman, Associate 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.