BVA9500259 DOCKET NO. 91-43 940 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUE Entitlement to service connection for atherosclerotic peripheral vascular disease with right above-the-knee amputation. REPRESENTATION Appellant represented by: Paul H. Kullen, Attorney WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD M. Siegel, Counsel INTRODUCTION The veteran served on active duty from April 1953 to April 1955. This appeal initially arose from a rating decision of August 1990 from the Detroit, Michigan, Regional Office (RO). In a decision dated in December 1991, the Board of Veterans' Appeals (Board) denied the veteran's claim; he thereafter appealed that determination to the United States Court of Veterans Appeals (Court). In [citation redacted], the Court vacated the Board's December 1991 decision, and remanded the case to the Board for further adjudication. By means of a remand decision dated in December 1993, the Board requested additional development of the record. Following accomplishment of that development, the RO confirmed and continued its prior denial of the veteran's claim in a rating decision dated in May 1994. The case was thereafter returned to the Board for appellate consideration. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends, in essence, that the RO erred when it denied service connection for atherosclerotic peripheral vascular disease with right above-the-knee amputation. He specifically alleges that this disability is etiologically related to his service-connected right leg varicose veins and right knee injury residuals. He asserts that he has had right leg problems since he injured his right knee while in service. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), has reviewed and considered all of the evidence and material of record in the veteran's claims file. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the preponderance of the evidence is against his claim for service connection for atherosclerotic peripheral vascular disease with right above-the-knee amputation. FINDINGS OF FACT 1. All evidence necessary for an equitable disposition of the veteran's claim has been developed. 2. Atherosclerotic peripheral vascular disease was not present during the veteran's active service, and is initially shown many years after his separation therefrom. Its manifestation at that time is not shown to be related to such service. 3. Atherosclerotic peripheral vascular disease with above-the- knee amputation is not shown to be etiologically or causally related to either right leg varicose veins or right knee injury residuals. CONCLUSIONS OF LAW 1. Atherosclerotic peripheral vascular disease with above-the- knee amputation was not incurred in or aggravated by active service, nor may it be presumed to have been incurred during such service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137 (West 1991); 38 C.F.R. §§ 3.303, 3.307, 3.309 (1993). 2. Atherosclerotic peripheral vascular disease with above-the- knee amputation is not proximately due to or the result of service-connected right leg varicose veins or right knee injury residuals. 38 C.F.R. § 3.310(a) (1993). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Initially, the Board finds that the veteran's claim is well grounded within the meaning of 38 U.S.C.A. § 5107(a) (West 1991); that is, he has presented a claim that is plausible. He has not indicated that any records of probative value that may be obtained and which have not already been associated with his claims folder are available. The Board accordingly finds that all relevant evidence has been properly developed, and that the duty to assist him, mandated by 38 U.S.C.A. § 5107(a) (West 1991), has been satisfied. As indicated above, the veteran contends that his atherosclerotic peripheral vascular disease with above-the-knee amputation is related to his period of active service, and that service- connection is accordingly warranted therefor. After a review of the record, however, the Board finds that his contentions are not supported by the evidence, and that his claim fails. The veteran's service medical records do not indicate that atherosclerotic peripheral vascular disease was manifested during his period of active service. The report of his entrance medical examination shows that his vascular system was clinically evaluated as normal, and does not note the presence of any peripheral vascular problems or symptoms thereof, or of complaints pertaining thereto. Service medical records dated thereafter likewise do not show that any peripheral vascular problems were identified or treated, or that the veteran complained of problems indicative of peripheral vascular disease. The report of the medical examination conducted in conjunction with his separation from service, while indicating the presence of right leg varicose veins, does not indicate that atherosclerotic peripheral vascular disease was manifested, nor does it indicate that he had been accorded treatment during service for such disease or that it had otherwise been identified during service. In fact, the medical evidence first indicates the presence of atherosclerotic peripheral vascular disease more than three decades after the veteran's separation from active service. Reports of Department of Veterans Affairs (VA) examinations conducted in 1959 and 1976 do not indicate that this disability, or symptoms thereof, had been discerned. While these and other medical records, to include a report of VA hospitalization in 1972 and a report of private hospitalization in 1975, show the presence of right leg varicose veins and thrombophlebitis, the evidence does not demonstrate that these problems were either manifestations of, or indicative of, atherosclerotic peripheral vascular disease; as discussed below, the medical evidence shows that varicose veins and atherosclerotic peripheral vascular disease are separate and distinct disorders that are not etiologically related to each other. The medical evidence first indicates the presence of peripheral vascular disease in October 1988, when the veteran was hospitalized with complaints of right foot pain of "one and half days" duration; his right leg was subsequently amputated above the knee in 1989, pursuant to treatment for "[s]evere peripheral vascular disease with gangrenous changes of the right lower extremity." It must be pointed out, however, that the October 1988 hospitalization record is dated more than 33 years after his separation from service. Neither this record, nor any other medical record, indicates that atherosclerotic peripheral vascular disease, or symptoms thereof, had been manifested prior to that date. In brief, the medical evidence does not demonstrate that atherosclerotic peripheral vascular disease was manifested during the veteran's period of active service, or for many years thereafter. In addition, the medical evidence does not demonstrate that the manifestation of atherosclerotic peripheral vascular disease in October 1988 was related to such service. See 38 C.F.R. § 3.303(d) (1993). It must accordingly be found that service connection cannot be granted on the premise that the disability at issue was manifested either in service or within one year after separation therefrom. See 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137 (West 1991); 38 C.F.R. §§ 3.307, 3.309 (1993). The veteran has also alleged, in essence, that his current atherosclerotic peripheral vascular disease is in some manner etiologically or causally related to his service-connected right knee injury residuals and right leg varicose veins. Service medical records pertaining to an inservice right knee injury, however, indicate that this injury was musculoskeletal in nature, with diagnoses and impressions to include right knee strain, right knee joint sprain, and sprained right medial collateral ligaments. These records do not show that any right knee injury the veteran incurred while in service involved the vascular system. In addition, no such involvement is demonstrated by the post service medical evidence. Reports of VA examinations conducted subsequent to his separation from service, to include examinations conducted in 1956, 1959, and 1976, while noting the presence of right knee musculoskeletal impairment, do not indicate the presence of any vascular disease related thereto. Although a private physician, identified as a practitioner of internal medicine, indicated in an April 1991 statement that the veteran's inservice knee problems and knee "bracing" was to some extent related to the veteran's arteriosclerosis, this opinion is apparently based on the history provided by the veteran, and is premised on an opinion that there is an etiological relationship between the knee injury and venous insufficiency, on the one hand, and arterial disease on the other. As previously noted, however, other medical evidence associated with the claims folder clearly indicates that there is no medical basis for holding that atherosclerotic peripheral vascular disease and venous thrombotic disease are etiologically or causally associated. Based on its review of the evidence, to include the April 1991 statement from the private physician, the Board must conclude that there is no etiological or causal relationship between the veteran's atherosclerotic peripheral vascular disease, with right leg above-the-knee amputation, and his service-connected right knee injury residuals, and that service connection for atherosclerotic peripheral vascular disease on this basis is not appropriate. See 38 C.F.R. § 3.310(a) (1993). The Board must also conclude that the evidence does not demonstrate the presence of an etiological or causal relationship between the veteran's atherosclerotic peripheral vascular disease and his service-connected right leg varicose veins. In this regard, the Board acknowledges that the private physician to which it referred above, in his April 1991 statement, indicated, in pertinent part, that "the [veteran's] venous problem...made his right leg more susceptible to ischemia due to arterial disease." In direct contrast are the findings indicated on a statement dated in March 1994 from a VA staff surgeon in vascular surgery, and which includes findings reached as a result of a recent examination of the veteran, and the reasons and bases for such findings. This statement indicates, in pertinent part, as follows: ...The disease entities of atherosclerotic peripheral arterial occlusive disease and venous thrombotic disease are distinct with regard to pathogenesis, treatment and natural history. Further, atherosclerotic arterial occlusive disease carries a recognized risk of progression to limb loss....When arterial disease progresses to produce the clinical symptoms of rest pain, limb loss is inevitable, in any population, unless timely intervention is undertaken. Venous disease...carries almost no threat of limb loss to the affected patient. There is no evidence to suggest that the presence of venous disease will make a patient susceptible to, cause, or worsen arterial occlusive disease. The [April 1991 private physician's] statement...has no scientific support. (Emphasis added.) This statement, in other words, clearly indicates that there is no basis for finding any etiological or causal relationship between varicose veins and atherosclerotic peripheral vascular disease, or even that the presence of the former disability will make a person "susceptible" to the latter disability. The Board must balance the private internist's statement, which in essence indicates only that the veteran's varicose veins in some manner and to some degree increased his susceptibility to atherosclerotic peripheral vascular disease, against the March 1994 statement from the VA vascular surgeon, which specifically refutes the opinion rendered by the internist. In determining the probative value of each statement, it must be pointed out that the March 1994 statement was proffered by a vascular specialist, whereas the April 1991 statement was not. It must also be noted that the former statement, to the effect that there was no relationship between venous thrombotic disease and arteriosclerotic peripheral vascular disease, contains findings very similar to those presented in a January 1990 statement from a vascular section chief of a VA medical facility, in which it was noted that the veteran's atherosclerotic peripheral vascular disease was "an acquired phenomena (sic) and cannot be attributed to [the veteran's] history of venous insufficiency." The Board must accordingly find, based on this evidence, that it is not shown that there is any relationship between his service- connected varicose veins and atherosclerotic peripheral vascular disease, and that service connection for atherosclerotic peripheral vascular disease on this basis is not warranted. See 38 C.F.R. § 3.310(a) (1993). In view of the foregoing, therefore, the Board must conclude that the preponderance of the evidence is against the veteran's claim for service connection for atherosclerotic peripheral vascular disease with right above-the-knee amputation. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137 (West 1991); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310(a) (1993). The veteran's claim accordingly fails. ORDER Service connection for atherosclerotic peripheral vascular disease with right above-the-knee amputation is denied. LAWRENCE M. SULLIVAN Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans' Judicial Review Act, Pub. L. No. 100-687, § 402 (1988). The date which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals.