Citation Nr: 25005602 Decision Date: 04/24/25 Archive Date: 04/24/25 DOCKET NO. 19-12 181 DATE: April 24, 2025 ORDER Service connection for right leg femoral occlusion, status post bypass graft is denied. Service connection for left leg stent is denied. Service connection for left neck main artery bypass is denied. FINDINGS OF FACT 1. The Veteran's right leg femoral occlusion, status post bypass graft was not caused or aggravated by service-connected coronary artery disease and is not otherwise related to an in-service injury or disease. 2. The Veteran's left leg stent was not caused or aggravated by service-connected coronary artery disease and was not otherwise related to an in-service injury or disease. 3. The Veteran's left neck main artery bypass was not caused or aggravated by service-connected coronary artery disease and was not otherwise related to an in-service injury or disease. CONCLUSIONS OF LAW 1. The criteria for service connection for right leg femoral occlusion, status post bypass graft due to service or service-connected coronary artery disease are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 2. The criteria for service connection for left leg stent due to service or service-connected coronary artery disease are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 3. The criteria for service connection for left neck main artery bypass due to service or service-connected coronary artery disease are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1966 to September 1969. Unfortunately, the Veteran died in March 2024. The Appellant is his surviving spouse, as indicated in the May 7, 2024, notification letter. The Board is grateful for the Veteran's service and regrets the Appellant's loss. These matters come before the Board of Veterans' Appeals (Board) on appeal from rating decisions issued in April 2017 and July 2017 by a Department of Veterans Affairs (VA) Regional Office. These matters were remanded by the Board in May 2022, May 2023, and July 2024 for additional development. It now returns to the Board for further appellate review. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 1. Entitlement to service connection for right leg femoral occlusion, status post bypass graft. 2. Entitlement to service connection for left leg stent. 3. Entitlement to service connection for left neck main artery bypass. It is contended that the Veteran's right leg femoral occlusion, status post bypass graft; left leg stent; and left neck main artery bypass were secondary to his service-connected coronary artery disease. With regard to the first element of service connection, the Board finds that the Veteran did have a current disability during the pendency of the appeal. Upon VA examination in August 2022, the Veteran's 2007 diagnosis of peripheral arterial disease was noted with the additional pertinent diagnoses of left neck main artery bypass (2013); right leg femoral occlusion, status post bypass (2013); and left leg stent (2013). Therefore, the primary inquiry before the Board is whether such diagnosed disabilities were caused or aggravated by the service-connected coronary artery disease. Upon VA examination in March 2017 for the Veteran's left neck carotid stenosis status post bypass graft; left leg stenosis, status post stent; and right leg femoral occlusion, status post bypass, the VA examiner opined that there is no causal relationship between peripherical vascular disease and coronary artery disease. In May 2017, the Veteran was afforded a VA examination for his conditions. The May 2017 VA examiner opined that the Veteran's left neck main artery bypass is not at least as likely as not due to or the result of coronary artery disease, status post coronary artery bypass graft. In support of this opinion, the examiner explained that the Veteran had symptomatic carotid disease in 2016. As rationale, the examiner explained that the Veteran suffered symptomatic carotid disease in 2016. A computed tomography angiography (CTA) showed a 75 percent stenosis of the left internal carotid artery requiring intervention in 2016. Therefore, a left carotid endarterectomy was performed in September 2016. In contrast, cardiovascular disease includes diseases such as cerebrovascular disease and peripheral artery disease. While carotid stenosis or atherosclerosis of carotids is within the spectrum of cardiovascular disease, the condition of carotid stenosis and coronary artery disease are two different vascular that affect different vessels. Therefore, the Veteran's carotid stenosis is less likely than not caused by his coronary artery disease. VA opinions were obtained in August 2022, September 2022, and December 2023; while such opinions also concluded that the Veteran's right leg femoral occlusion, status post bypass graft; left leg stent; and left neck main artery bypass were not caused or aggravated by service-connected coronary artery disease, their rationales were legally inadequate, as explained in prior Board remands. Upon VA examination consisting of a record review in August 2024, the examiner indicated that the Veteran's right leg femoral occlusion, status post bypass graft; left leg stent; and left neck main artery bypass are due to peripheral vascular disease and noted the Veteran's chronic hypertension, hyperlipidemia, and chronic smoking history. The August 2024 VA examiner opined that the Veteran's right leg femoral occlusion, status post bypass graft; left leg stent; and left neck main artery bypass are less likely than not caused or aggravated by the coronary artery disease as the narrowing of a blood vessel in one part of the body does not cause narrowing of another vessel unless there is an embolus. The examiner explained that an embolus is a piece of plaque that is dislodged from the original site and then causes a clot in another portion, the examiner explained that such did not occur in the Veteran's case. In the Veteran's case, the examiner noted that the Veteran had hypertension, hyperlipidemia, and smoking history, which are three of the most significant factors of peripheral vascular disease. In February 2025, VA obtained an addendum opinion. The February 2025 VA examiner explained that the Veteran's right leg femoral occlusion, status post bypass graft; left leg stent; and left neck main artery bypass was less likely than not aggravated by the coronary artery disease. In support of this opinion, the examiner explained that narrowing of the blood vessel of the coronary arteries, which are located in the heart, do not physically nor pathophysiologically lead to narrowing of blood vessels elsewhere in the body. The examiner explained that factors such as hypertension, hyperlipidemia, and smoking cause damage to the walls of blood vessels which frays the smooth walls and increases the likelihood that debris and other substances like lipids and chemicals from smoking can attach and cause narrowing. The February 2025 VA examiner also opined that the Veteran's right leg femoral occlusion, status post bypass graft; left leg stent; and left neck main artery bypass were less likely than not caused by the coronary artery disease. In support of this opinion, the examiner explained that the narrowing of a blood vessel in one part of the body does not cause narrowing of another vessel unless there is an embolus, which did not occur in the case of the Veteran. The examiner explained that the Veteran's condition was a natural progression and not related to any service-connected disease or injury. The Board acknowledges that the multiple VA examiners included hyperlinks to content that is not otherwise part of the record on appeal. While the Board could review evidence submitted via hyperlink, because hyperlinked information may not be static, the Board would be unable to determine whether what the Board saw when it accessed the hyperlinked information was what the Veteran intended to submit as evidence, or what the examiner intended to rely on. As the Board cannot create evidence, what was found at the hyperlinked address would not be part of the record. In turn, the United States Court of Appeals for Veterans Claims would be unable to perform meaningful appellate review of evidence that is not in the record. Given the foregoing, the Board advises that hyperlinked references were not reviewed. The record does not reflect, and the Appellant does not contend that there is entitlement to service connection on a direct basis. The Board finds that the May 2017, August 2024, and February 2025 VA examiner's opinions are highly probative as to the opinions they provide. In this regard, the opinions properly considered the specific circumstances of the Veteran and provide a rationale for the opinions provided. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). Notably, there are no opinions to the contrary. Based on the foregoing, service connection is not warranted for right leg femoral occlusion, status post bypass graft; left leg stent; and left neck main artery bypass. As the weight of the evidence is against the claim, the benefit of the doubt doctrine is not for application. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Nathaniel Doan Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. M. Younan 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.