ANEURYSM ANY LARGE ARTERY

Summary

The Veteran, an Army veteran who served from January 1968 to August 1969, appeals the denial of service connection for a dilated aorta and a renal cyst, both claimed as secondary to his service-connected hypertension. The Board granted service connection for the dilated aorta, finding that the Veteran's private medical records and the opinion of his private practitioner established the necessary nexus. The practitioner noted that the Veteran's hypertension plays a role in the progression of his aortic disease and dilation, satisfying the "but-for" causation standard for secondary service connection. However, the Board remanded the claim for a renal cyst due to an inadequate VA examination. The VA examiner provided a negative opinion, stating the renal cyst was less likely than not related to hypertension or herbicide exposure, but used an incorrect "proximate cause" standard and failed to discuss aggravation. The medical literature submitted by the Veteran was inconclusive regarding a link between renal cysts and hypertension. Therefore, the case was remanded for a new VA examination to obtain a proper opinion on the secondary service connection and aggravation of the renal cyst, considering the Veteran's service-connected disabilities and medications.

Rationale

Private practitioner opinion noted hypertension's role in aortic dilation progression; Satisfied "but-for" causation standard for secondary service connection; Satisfied elements of current diagnosis, service-connected primary disability, and nexus

Full Decision Text

Citation Nr: A26032821
Decision Date: 04/09/26	Archive Date: 04/09/26

DOCKET NO. 251205-605297
DATE: April 9, 2026

ORDER

Entitlement to service connection for a condition manifested by a dilated aorta, as secondary to the Veteran's service-connected hypertension disability, is granted.

REMANDED

Entitlement to service connection for a renal cyst condition, to include as secondary to the Veteran's service-connected disabilities, including hypertension, is remanded.

FINDINGS OF FACT

The evidence of record supports a finding that the Veteran's service-connected hypertension disability has resulted in the progression of the Veteran's dilated aorta condition. 

CONCLUSION OF LAW

The criteria for secondary service connection for a condition manifested by a dilated aorta are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.104, 3.303, 3.310.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served in the United States Army from January 1968 to August 1969, with additional Reserve service.  

The decision on appeal to the Board of Veterans' Appeals (Board) from the regional office (referred to as the Agency of Original Jurisdiction (AOJ)), was issued in July 2025. Therefore, the modernized review system, also known as the Appeals Modernization Act (AMA), applies.  

In December 2024, the Veteran filed VA Form 21-526EZ (Claim) requesting service connection for a dilated aorta, as secondary to his service-connected hypertension; and service connection for a renal cyst, as secondary to his service-connected hypertension. In July 2025, the AOJ denied service connection for both issues. 

In December 2025, the Veteran filed VA Form 10182 (Notice of Disagreement), requesting review of the July 2025 rating decision with regard to the noted issues, and requesting the Evidence Review docket. The appeal was docketed in December 2025. 

Therefore, the Board may only consider the evidence of record at the time of the July 2025 decision, which was identified as the decision being appealed; and any evidence submitted by the Veteran, or his Representative, with or within 90 days from receipt of, the Notice of Disagreement. 38 C.F.R. § 20.303. If evidence was submitted either (1) during the period after the AOJ issued the July 2025 decision and prior to the date the Board received the Notice of Disagreement, or (2) more than 90 days following the date the Board received the Notice of Disagreement, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.303, 20.801.

The Board notes that the Veteran waived his due process right to switch dockets within one year of receipt of the July 2025 rating decision notification letter; additionally, the Veteran waived his right to submit additional evidence within 90 days of the Board's receipt of the December 2025 Notice of Disagreement. See December 2025 Notice of Disagreement (requesting expeditious adjudication of the issues); 38 C.F.R. §§ 20.202(c)(2), 20.300, 20.303, 20.801.

If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claim, considering the new evidence in addition to the evidence previously considered. 38 C.F.R. § 3.2501. Specific instructions for filing a Supplemental Claim are included with this decision.

The Board is required by statute to adjudicate cases in docket order, except for certain situations set forth under 38 U.S.C. § 7107. A motion for advancement on the docket (AOD) may be granted in certain circumstances, to include if a Veteran is seriously ill, under severe financial hardship, or if other sufficient cause is shown-to include being age 75 or older.  38 C.F.R. § 20.800(c)(1). Here, the Veteran requested consideration for advancement on the docket based on the Veteran's age; however, the motion was previously granted.

Service Connection

The Veteran asserts that his dilated aorta and renal cyst condition are related to his military service. See December 2024 (Claim) (noting that the Veteran was requesting service
 except for certain situations set forth under 38 U.S.C. § 7107. A motion for advancement on the docket (AOD) may be granted in certain circumstances, to include if a Veteran is seriously ill, under severe financial hardship, or if other sufficient cause is shown-to include being age 75 or older.  38 C.F.R. § 20.800(c)(1). Here, the Veteran requested consideration for advancement on the docket based on the Veteran's age; however, the motion was previously granted.

Service Connection

The Veteran asserts that his dilated aorta and renal cyst condition are related to his military service. See December 2024 (Claim) (noting that the Veteran was requesting service connection for dilated aorta and a renal cyst condition as secondary to his service-connected hypertension). 

Relevant Legal Principles

To establish service connection, a Veteran must show: (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d. 1163, 1166-67 (Fed. Cir. 2004). 

Additionally, service connection is granted for a disability resulting from disease or injury incurred in or aggravated by active duty. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.304. Service connection may be granted for any disease initially diagnosed after service when all the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d).

Secondary service connection may be established for a disability that is shown to be due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a); Spicer v. McDonough, 61 F.4th 1360, 1364 (Fed. Cir. 2023). To prevail under secondary service connection, the record must show: (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical nexus evidence establishing a connection between the service-connected disability and the current disability. Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995).

Such secondary service connection is warranted for any increase in severity of a nonservice-connected disability that is proximately due to or the result of a service-connected disease or injury.  38 C.F.R. § 3.310(b) see also Spicer, 61 F.4th at 1364 (invalidating the requirement of "proximate cause" and instead holding that "but for" causation or aggravation is sufficient to show entitlement to secondary service connection). Pursuant to Spicer, secondary service connection is warranted where a non-service-connected disability would have been less severe "but for" a service-connected disability, either because there is an etiological link (to include worsening of functionality) between the two, or because the service-connected disability resulted in the inability to treat the non-service-connected disability.

Additionally, the Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxics Act of 2022 (PACT Act), effective August 10, 2022, requires a disability examination and medical opinion be requested for certain non-presumptive conditions involving toxic exposure risk activity (TERA). For such claims, VA is required to provide a disability examination and medical opinion when (1) the Veteran submits a claim for compensation, (2) has evidence of a disability, (3) has evidence of participation in a TERA, and (4) such evidence is not sufficient to establish service connection for the disability. 38 U.S.C. § 1168.

A Veteran can claim participation in a TERA explicitly or implicitly through service in a location presumed associated with toxic exposure, or records showing participation in a TERA; or, if VA has conceded exposure in a prior claim, or the file has a claim attributable to toxic exposure. Other ways to claim or establish participation in a TERA include, when a Veteran's military occupational specialty (MOS) is associated with toxic exposure; when medical records suggest exposure to a toxic substance, chemical, or airborne hazard such as VHA exposure screening; or, with any other relevant evidence of record, to include garrison exposures. 38 U.S.C. § 1168.

When VA provides an examination, it must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 310-11 (2007). For a medical opinion to be adequate,
 showing participation in a TERA; or, if VA has conceded exposure in a prior claim, or the file has a claim attributable to toxic exposure. Other ways to claim or establish participation in a TERA include, when a Veteran's military occupational specialty (MOS) is associated with toxic exposure; when medical records suggest exposure to a toxic substance, chemical, or airborne hazard such as VHA exposure screening; or, with any other relevant evidence of record, to include garrison exposures. 38 U.S.C. § 1168.

When VA provides an examination, it must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 310-11 (2007). For a medical opinion to be adequate, the opinion must support its conclusion with an analysis that the Board can weigh, and a mere conclusion by a medical doctor is insufficient to allow the Board to make an informed decision. Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007). Moreover, a medical opinion is inadequate when it fails to adequately address the question of aggravation. El-Amin v. Shinseki, 26 Vet. App. 136, 140 (2013).

Lay statements made by a Veteran can be competent and credible when they relate to evidence derived from the witness's own personal knowledge and limited to what the witness has observed through the senses. Layno v. Brown, 6 Vet. App. 465, 470 (1994). 

In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Layno, 6 Vet. App. at 469; see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify").

Additionally, favorable findings made by the AOJ are binding on all subsequent AOJ and Board adjudicators, unless rebutted by evidence that identifies a clear and unmistakable error. 38 C.F.R. § 3.104.

Finally, the Board must determine whether the evidence persuasively favors the claim or if there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, with the Veteran prevailing in either event, or whether the evidence persuasively weighs against the claim in which case it must be denied. See Lynch v. McDonough, 21 F.4th 776, 778 (Fed. Cir. 2021). The Veteran is entitled to the benefit of the doubt when there is an "approximate balance" (meaning nearly equal) between evidence regarding any material determination. Id. at 781-82; 38 U.S.C. § 5107; 38 C.F.R. § 3.102.

Facts and Analysis

To begin, the AOJ conceded that the Veteran has a current diagnosis of renal cyst and that the claimed primary disability (hypertension) is service connected. Additionally, the AOJ conceded that the Veteran participated in toxic exposure risk activity (TERA) including exposure to the herbicide agent, Agent Orange. See July 2025 Rating Decision; 38 C.F.R. § 3.104.

The relevant evidence on review includes service treatment records, treatment records, and VA examinations from May 2025. 

The Veteran's service treatment records are silent for cardiac issues (including a dilated aorta) and renal cysts. See June 1967 and August 1968 Reports of Medical History and Examination (noting a normal examination). 

On examination, the Veteran reported "cardiac symptoms of chest pain and palpitations" and a diagnosis of dilated aorta. See May 2025 VA Examination. However, the examiner did not offer a cardiac diagnosis. Id. (noting that although the Veteran reported abnormal findings of a dilated aortic arch, the records were not in the file, and no diagnostic testing was performed). Insofar as the VA examiner did not perform any diagnostic tests, the examination is not probative for service connection purposes. Barr, 21 Vet. App. at 310-11; Stefl, 21
 cysts. See June 1967 and August 1968 Reports of Medical History and Examination (noting a normal examination). 

On examination, the Veteran reported "cardiac symptoms of chest pain and palpitations" and a diagnosis of dilated aorta. See May 2025 VA Examination. However, the examiner did not offer a cardiac diagnosis. Id. (noting that although the Veteran reported abnormal findings of a dilated aortic arch, the records were not in the file, and no diagnostic testing was performed). Insofar as the VA examiner did not perform any diagnostic tests, the examination is not probative for service connection purposes. Barr, 21 Vet. App. at 310-11; Stefl, 21 Vet. App. at 124-25. As such, the Board gives it no weight. 

On the other hand, the Veteran's private treatment records note that the Veteran had a diagnosis for a dilated ascending thoracic aorta in September 2017. See September 2017, October 2018 Private Treatment Records (received June 2025); May 2025, September 2025, October 2025 Private Treatment Records (received December 2025).

As the Veteran's private treatment records confirm a current diagnosis for a dilated aorta, elements one (current diagnosis) and two (service-connected hypertension disability) are met. 38 C.F.R. §§ 3.104, 3.310(a); Wallin, 11 Vet. App. at 512. As such, the question then becomes whether there is a link between the two. 

To that end, the Veteran's private practitioner noted that they discussed "the risk of [hypertension] on [the] progression of [the Veteran's] aortic disease and dilation." See September 2025 Private Treatment Records (received December 2025).

The Board finds that element three (nexus) for secondary service connection has been met. Because the Veteran's private practitioner noted that the Veteran's hypertension plays a role in the progression of the symptomatology of the Veteran's dilated aorta, but-for causation has been established. See Spicer, 61 F.4th at 1364 (stating that secondary service connection is appropriate when the non-service-connected disability would have been less severe were it not for the service-connected disability); 38 C.F.R. § 3.310(a); Wallin, 11 Vet. App. at 512. 

Because all three elements for secondary service connection are met, the Board finds that the persuasive weight of the evidence supports entitlement to service connection for a dilated aorta, as secondary to the Veteran's service-connected hypertension disability. See Lynch, 21 F.4th at 778; Spicer, 61 F.4th at 1364. As such, the appeal is granted. 38 C.F.R. §§ 3.104, 3.310(a). 

REASONS FOR REMAND 

Relevant Legal Criteria

The United States Court of Appeals for Veterans has held that a medical article or treatise "can provide important support when combined with an opinion of a medical professional" if the medical article or treatise evidence discussed generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least "plausible causality" based upon objective facts rather than on an unsubstantiated medical opinion. Sack v. West, 11 Vet. App. 314, 316-317 (1998) (noting that "too general and inconclusive" statements cannot form a well-grounded claim without more substantive evidence); see also Wallin, 11 Vet. App. at 514 (stating that medical treatise evidence discussed generic relationships with a degree of certainty to establish a plausible causality of nexus); Mattern v. West, 12 Vet. App. 222, 228 (1999). 

Under the AMA, the Board shall remand an appeal to the AOJ for correction of an error by the AOJ which occurred prior to the rating decision on appeal, including those relating to VA examinations. See 38 C.F.R. § 20.802. The Board may also remand for correction of any other error by the AOJ to satisfy a regulatory or statutory duty, if correction of the error would have a reasonable possibility of aiding in substantiating the Veteran's claim. Id.

Facts and Analysis 

As the AOJ conceded that the Veteran has a current diagnosis of renal cyst and hypertension is service-connected, the question then becomes whether there is a link between the two. See July 2025 Rating Decision; 38 C.F.R. §§ 3.104, 3.310(a); Wallin, 11 Vet. App. at 512.

The relevant evidence on review includes VA examinations from May 
 examinations. See 38 C.F.R. § 20.802. The Board may also remand for correction of any other error by the AOJ to satisfy a regulatory or statutory duty, if correction of the error would have a reasonable possibility of aiding in substantiating the Veteran's claim. Id.

Facts and Analysis 

As the AOJ conceded that the Veteran has a current diagnosis of renal cyst and hypertension is service-connected, the question then becomes whether there is a link between the two. See July 2025 Rating Decision; 38 C.F.R. §§ 3.104, 3.310(a); Wallin, 11 Vet. App. at 512.

The relevant evidence on review includes VA examinations from May 2025 and medical literature submitted by the Veteran. 

Beginning with the May 2025 VA examination, the examiner offered a negative secondary service connection opinion, stating that: 

"[t]he claimed [renal cyst] is less likely than not (likelihood is less than approximately balanced or nearly equal) proximately due to or the result of the Veteran's service connected [hypertension] condition . . . . [as the conditions] are not medically related. The [renal cyst condition] is a separate entity entirely from the hypertension and unrelated to it. A thorough review of medical literature failed to demonstrate a causal relationship. A nexus has not been established . . . . While some studies have identified hypertension as a risk factor for the presence of renal cysts in cross-sectional analyses, these associations are confounded by age, renal function, and other comorbidities, and do not establish a direct causal pathway from hypertension to cyst formation." 

See May 2025 VA Examination. 

However, as the examiner used the incorrect proximate cause standard in evaluating secondary service connection, rather than the but-for standard, and failed to discuss aggravation, the May 2025 examination is inadequate for secondary service connection purposes. Spicer, 61 F.4th at 1364; El-Amin, 26 Vet. App. at 140. As such, the Board gives it little weight. 

Additionally, the examiner considered the Veteran's TERA activities. In explaining the negative nexus opinion, the examiner stated that: 

"[t]he current medical literature does not support that . . . a renal cyst to be at least as likely as not caused by exposure to herbicide agents, specifically 2,3,7,8-tetrachlorodibenzodioxin (TCDD), even when considering cumulative and synergistic toxic exposures during military service. Epidemiological studies and exposure modeling consistently demonstrate that, except for specific subgroups with direct, high-level occupational contact (e.g., mixer/loaders, applicators, or those with documented direct handling of Agent Orange), most Vietnam-era military personnel-including ground troops-had TCDD exposures similar to or only marginally above background levels found in the general population . . . . Furthermore, the medical literature does not establish a causal or statistically significant association between TCDD exposure and benign kidney conditions such as renal cysts. Large-scale epidemiologic reviews and cohort studies of exposed populations, including Vietnam Veterans and occupationally exposed workers, have not demonstrated an increased risk of kidney disease or renal cysts attributable to TCDD exposure." 

See May 2025 VA Examination. 

As the examiner explained the reasoning behind the negative TERA opinion, the Board finds it adequate and probative. Barr, 21 Vet. App. at 310-11; Stefl, 21 Vet. App. at 124-25. As such, the Board gives it some weight.

In support of the nexus element, the Veteran submitted medical literature. However, the majority of the literature discussed the proposition that renal cysts may increase the risk for hypertension-not vice versa. See generally December 2025 Medical Literature (reporting in "Relationship of Simple Renal Cyst to Hypertension," that a "newly diagnosed simple renal cyst was found to be associated with increased risk of hypertension;" a "large renal cyst may increase risk of hypertension;" and the authors "believe that regardless of [the] number . . . , bilateral renal cysts may increase the risk of hypertension") (stating in "Multiple and large simple renal cysts are associated with prehypertension and hypertension," that "[m]ultiple and large simple renal cysts are associated with prehypertension and hypertension," and "subjects with [simple renal cysts] presented a consistent higher risk for hypertension regardless of the cyst's characteristics"); but see Relationship of Simple Renal Cyst to Hypertension (noting that one study reported that hypertension may induce kidney dysfunction, leading to renal cyst formation).

The Board finds that because the medical literature is inconclusive, it is inadequate on its own to support a nexus for secondary service connection. See Sack, 11 Vet. App. at
 , bilateral renal cysts may increase the risk of hypertension") (stating in "Multiple and large simple renal cysts are associated with prehypertension and hypertension," that "[m]ultiple and large simple renal cysts are associated with prehypertension and hypertension," and "subjects with [simple renal cysts] presented a consistent higher risk for hypertension regardless of the cyst's characteristics"); but see Relationship of Simple Renal Cyst to Hypertension (noting that one study reported that hypertension may induce kidney dysfunction, leading to renal cyst formation).

The Board finds that because the medical literature is inconclusive, it is inadequate on its own to support a nexus for secondary service connection. See Sack, 11 Vet. App. at 316-317; Wallin, 11 Vet. App. at 514. 

As no nexus has been established and the May 2025 VA examination opinion for secondary service connection is inadequate as to the issue of secondary service connection, remand is necessary to cure this pre-decisional duty to assist error. See 38 C.F.R. § 20.802(a).

The matter is REMANDED for the following action:

Obtain an opinion from an appropriate clinician regarding the nature and etiology of the Veteran's claimed renal cyst condition. If an opinion cannot be provided without an examination, the Veteran should be scheduled for a new examination.

If the examiner determines it to be necessary, an examination should be conducted and any indicated tests, studies, or evaluations should be performed. If an examination is conducted, obtain the Veteran's detailed lay history, including onset and the progression of the symptomatology of his claimed renal cyst condition.

The examiner is asked to address the following:

(a.) Determine whether it is at least as likely as not (i.e., likelihood is at least approximately balanced or nearly equal) that the Veteran's service-connected disabilities, including hypertension, caused his claimed renal cyst condition. Why or why not?

(b.) Determine whether it is at least as likely as not (i.e., likelihood is at least approximately balanced or nearly equal) that the Veteran's service-connected disabilities, including hypertension, aggravated his claimed renal cyst condition. Why or why not?

Determine whether it is at least as likely as not (i.e., likelihood is at least approximately balanced or nearly equal) that the medications the Veteran takes for his service-connected disabilities, including hypertension, caused his claimed renal cyst condition. Why or why not?

(c.) Determine whether it is at least as likely as not (i.e., likelihood is at least approximately balanced or nearly equal) that the medications the Veteran takes for his service-connected disabilities, including hypertension, aggravated his claimed renal cyst condition. Why or why not? 

(d.) For any aggravation found, the examiner should state, to the best of their ability, the baseline of symptomatology and the amount, quantified if possible, of aggravation beyond the baseline symptomatology. 

For the purpose of responding to the questions posed above, the Board notes that the Veteran is currently service-connected for the following disabilities: hypertension; major depressive disorder; diabetes mellitus with erectile dysfunction; urinary frequency; left and right upper extremity diabetic neuropathy, radial nerve; left and right lower extremity diabetic neuropathy, sciatic nerve; and hyposmia. 

A complete medical rationale for all opinions expressed must be provided.

The term "at least as likely as not" does not mean "within the realm of medical possibility." Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of the conclusion (e.g., diagnosis, etiology) as it is to find against the conclusion.

The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be acknowledged and considered in formulating any opinion.

The examiner should also be aware that in rendering an opinion, it must "contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two." See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008).

Furthermore, if medical literature is relied upon in rendering this determination, the VA examiner should identify and specifically cite each reference material utilized.

Citation to accepted medical literature and principles would be of great assistance to the Board. If the medical professional is unable to provide any opinion without 

?

resorting to speculation, he or she must explain why this is so. 

 

M. C. WILSON

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	L. Davidson

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.