Bilateral Lower Limbs - Varicose Veins — DVA claim example

Diagnostic Assessment — Bilateral Lower Limbs - Varicose Veins

Example 1 of 1 · fictitious patient (Veteran BV)

Diagnostic Assessment

Bilateral Lower Limbs - Varicose Veins

BOP Code: 8 of 2021 (Chronic Venous Insufficiency of the Lower Limb and Varicose Veins of the Lower Limb)
RH Code: 7 of 2021 (Chronic Venous Insufficiency of the Lower Limb and Varicose Veins of the Lower Limb)

ADF History

Veteran BV, date of birth 04 April 1982, Australian Army, Cook (Corporal), enlisted 12 February 2001, medically discharged 20 July 2018. Operational service: Afghanistan, 01 February 2007 to 15 August 2007 (warlike); Middle East Area of Operations, 10 June 2009 to 24 November 2009 (warlike).

Occupational History

As an Army cook the veteran prepared meals in garrison kitchens, field kitchens and deployed dining facilities. The work requires standing for most of a shift on hard floors, typically 8 to 12 hours a day in garrison and up to 14 hours a day in the field and on operations, with lifting of stock pots, trays and supply boxes of 15 to 25 kilograms and repeated bending into ovens and storerooms.

Kitchens are hot and humid, and long shifts standing in heat promote venous pooling in the legs. On operations cooks work in exposed base facilities subject to indirect fire, travel on long-haul military flights, and have limited access to compression garments, specialist vascular care and imaging.

History

Veteran BV, an Army cook, developed bilateral varicose veins of the thighs and calves on 18 May 2010 while pregnant, after more than nine years of prolonged standing in kitchens, a fragment wound to the right thigh in Afghanistan in 2007, and a left ankle fracture complicated by deep vein thrombosis, iliac vein obstruction and pulmonary embolism on deployment in the Middle East in 2009. She developed chronic venous insufficiency in March 2013, and the condition worsened with a venous ulcer during a second pregnancy, documented on 14 June 2016.

Timeline

• 12 May 2007 — During warlike service in Afghanistan a rocket struck near the base kitchen and a metal fragment penetrated the veteran's right upper medial thigh. At the role 3 hospital the wound was explored and a laceration of the great saphenous vein close to the saphenofemoral junction was repaired. The surgeon recorded damage to the terminal valve of the vein. She returned to kitchen duties after three weeks. "fragment wound, GSV repaired"
• 15 Apr 2009 — Pre-deployment medical examination recorded no varicose veins, no leg swelling and normal peripheral pulses. Weight 86 kg, height 1.66 m, BMI 31.2. She was assessed as fit to deploy to the Middle East as a field kitchen cook working 12 to 14 hour shifts. "no varicosities, BMI 31.2"
• 20 Nov 2009 — On warlike service in the Middle East the veteran fell down the steps of a kitchen container while carrying a supply box and sustained a trimalleolar fracture of the left ankle. It was immobilised in a below-knee cast and she was aeromedically evacuated on 24 November 2009 on a long-haul flight of about 24 hours. On 27 November 2009 she developed a swollen left leg and chest pain, and duplex ultrasound and CT pulmonary angiography confirmed left femoral and popliteal deep vein thrombosis with bilateral pulmonary emboli. "L ankle fracture, DVT, PE"
• 24 Feb 2010 — CT venography showed chronic post-thrombotic narrowing of the left common iliac vein with pelvic collateral varices draining across the pelvis and into the upper thighs. Echocardiography showed moderate tricuspid regurgitation with a pulmonary artery systolic pressure of 55 mmHg, consistent with chronic thromboembolic pulmonary hypertension. Left ankle dorsiflexion was limited to 0 degrees after cast removal. "iliac narrowing, moderate TR"
• 10 Mar 2010 — Right heart catheterisation via the right femoral vein confirmed pulmonary hypertension. An inadvertent puncture of the adjacent artery resulted in a right common femoral arteriovenous fistula, confirmed on duplex ultrasound on 22 March 2010 and managed conservatively. Vascular examination before the procedure recorded no varicose veins in either leg. Pregnancy was confirmed on 30 March 2010. "femoral AV fistula post-catheter"
• 25 May 2010 — At 17 weeks of pregnancy the veteran presented to the garrison health centre with one week of aching, heavy legs at the end of kitchen shifts and newly visible bulging veins in both thighs and calves. Examination showed varicosities of the great saphenous territories bilaterally, vulval and posterior thigh varices on the left, and a visibly pulsatile right great saphenous vein. Weight before pregnancy 88 kg, BMI 31.9. Referral to a vascular surgeon was made. "bilateral varicose veins, pulsatile GSV"
• 18 Mar 2013 — The veteran was reviewed with brown pigmentation, eczema and hardening of the skin of the left lower leg and ankle oedema bilaterally. Right heart failure from pulmonary hypertension had been diagnosed on 02 March 2013, with a dilated right ventricle and diuretics commenced. BMI 33.4. Chronic venous insufficiency, CEAP class C4, was diagnosed. She was still working as a senior cook on her feet for most of each shift. "CVI C4, right heart failure"
• 14 Jun 2016 — At 22 weeks of a second pregnancy the veteran presented with rapidly enlarging varicose veins in both legs and a 3 cm venous ulcer above the left medial malleolus. She had a recurrent left calf deep vein thrombosis on 02 February 2016. Duplex ultrasound showed new deep and superficial reflux and enlarged varices compared with 2010. BMI before pregnancy 35.1. CEAP class C6. "venous ulcer, worsening varicosities"

Symptoms

At onset the veteran had aching, heaviness and swelling of both legs at the end of each kitchen shift, with newly visible bulging veins in both thighs and calves and vulval veins on the left. Symptoms were worse in heat and after long periods of standing and eased overnight with elevation. Over the following months she had night cramps, itching over the veins and visible pulsation of the right great saphenous vein.

From 2013 she had skin pigmentation and hardening around the left ankle and persistent ankle swelling, and from June 2016 a painful venous ulcer above the left ankle. She now reports daily leg aching and swelling, cannot stand for more than 30 minutes, wears class 2 compression stockings daily and has recurrent skin breakdown at the left ankle.

Imaging

• 27 Nov 2009 — Duplex ultrasound left leg and CT pulmonary angiogram: "Occlusive thrombus in the left common femoral, femoral and popliteal veins. Bilateral segmental pulmonary emboli."
• 24 Feb 2010 — CT venogram abdomen and pelvis: "Chronic post-thrombotic narrowing of the left common iliac vein of about 70 per cent with extensive pelvic and vulval collateral varices communicating with the left posterior thigh veins."
• 22 Mar 2010 — Duplex ultrasound right groin: "Arteriovenous fistula between the right common femoral artery and vein at the catheterisation site, with arterialised flow in the common femoral vein."
• 03 Jun 2010 — Venous duplex ultrasound both legs: "Bilateral great saphenous vein reflux with varicose tributaries. Incompetent right saphenofemoral junction with a scarred terminal valve and pulsatile flow. Left post-thrombotic popliteal and femoral vein reflux. Reflux from pelvic varices into the left posterior thigh veins."
• 14 Jun 2016 — Venous duplex ultrasound both legs: "Enlarged bilateral varices and extended great saphenous reflux. New left calf vein thrombus with recanalisation. Increased deep venous reflux on the left compared with 03 June 2010."

Onset Date

The most likely date of onset of this condition is 18 May 2010.

At that date the veteran was serving full time as a cook in a garrison kitchen, about 16 weeks pregnant, and was standing for 8 to 10 hours on most working days. She had returned to standing duties in February 2010 after the left ankle fracture, deep vein thrombosis and pulmonary emboli she sustained on warlike service in late 2009, and she had a right femoral arteriovenous fistula, left iliac vein narrowing with pelvic varices and moderate tricuspid regurgitation.

This date is appropriate because the vascular examination of 10 March 2010 recorded no varicose veins in either leg, and she first presented on 25 May 2010 with one week of aching legs and newly visible varicose veins, confirmed on duplex ultrasound on 03 June 2010. The veins appeared during continuous full-time service.

For the standing factor, the five years before onset run from 18 May 2005 to 18 May 2010. Throughout that period she worked as a cook in garrison and on deployments in Afghanistan in 2007 and the Middle East in 2009, standing for 8 to 14 hours a day on more days than not, apart from about ten weeks in a cast from November 2009. The deep vein thrombosis (27 Nov 2009), the iliac vein obstruction (24 Feb 2010), the valve trauma (12 May 2007) and the arteriovenous fistula (10 Mar 2010) all occurred before onset. Pregnancy, obesity, chronic calf muscle pump dysfunction from the stiff left ankle, tricuspid regurgitation with a pulsatile great saphenous vein and pelvic varices were all present on 18 May 2010. Chronic venous insufficiency developed later, on 18 Mar 2013, when varicose veins, right heart failure and obesity were each present.

For the worsening factors, the documented worsening was on 14 Jun 2016, during her second pregnancy, with a venous ulcer and enlarged varices on duplex. The five years before the worsening run from 14 Jun 2011 to 14 Jun 2016, during which she worked full time as a senior cook on her feet for most of each shift after returning from maternity leave on 10 Jan 2011. A recurrent left calf deep vein thrombosis occurred on 02 Feb 2016, before the worsening, and pregnancy, obesity, heart failure, the arteriovenous fistula, tricuspid regurgitation and the stiff left ankle were all present on 14 Jun 2016.

1. What is the formal diagnosis of the condition claimed above?

The formal diagnosis is Bilateral Lower Limbs - Varicose Veins (ICD-10-AM I83.9), with secondary chronic venous insufficiency from March 2013, under the Statements of Principles concerning chronic venous insufficiency of the lower limb and varicose veins of the lower limb, Balance of Probabilities No. 8 of 2021 and Reasonable Hypothesis No. 7 of 2021.

Varicose veins are dilated, elongated and tortuous superficial veins of the legs, usually caused by failure of the one-way valves that keep blood flowing up the leg towards the heart. When the valves fail, blood flows backwards and pools, raising the pressure in the superficial veins, which stretch and bulge. Prolonged standing, pregnancy, obesity, damage to the valves from injury or deep vein thrombosis, obstruction of the deep or pelvic veins, raised right heart pressures and poor function of the calf muscle pump all contribute. Persisting high venous pressure can lead to chronic venous insufficiency, with swelling, skin pigmentation, eczema, hardening of the skin and, eventually, venous ulceration.

The varicose veins began on 18 May 2010, after prolonged standing as a cook, a fragment wound to the right great saphenous vein in Afghanistan, and deep vein thrombosis with iliac vein obstruction and pulmonary hypertension following an injury on warlike service in the Middle East. Chronic venous insufficiency followed in March 2013, and the condition worsened with a venous ulcer in June 2016.

2. For each diagnosis identified, please also provide the following dates:

When did the veteran first experience symptoms attributable to this condition?

18 May 2010.

When did the veteran first present to a health / medical provider for this condition?

25 May 2010.

When was the condition confirmed / formally diagnosed?

03 June 2010.

When did the veteran first present to you (or your practice) for this condition?

29 July 2025.

3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?

The diagnosis was confirmed by venous duplex ultrasound on 03 June 2010, which showed bilateral great saphenous vein reflux with dilated tortuous tributaries, an incompetent right saphenofemoral junction with a scarred terminal valve, left post-thrombotic deep venous reflux and reflux from pelvic varices into the left posterior thigh veins. Clinical examination on 25 May 2010 showed visible varicosities in both thighs and calves, consistent with the Statement of Principles definition of varicose veins of the lower limb.

Chronic venous insufficiency was diagnosed on 18 March 2013 on the basis of pigmentation, venous eczema, lipodermatosclerosis and oedema (CEAP class C4). The worsening was confirmed on 14 June 2016 by a venous ulcer above the left medial malleolus (CEAP class C6) and duplex ultrasound showing enlarged varices and increased deep venous reflux compared with 2010.

4. What do you consider to be the cause(s) of the condition in this veteran? Give consideration to constitutional and common risk factors, pre-existing injuries or diseases, and occupational or lifestyle risks, as well as direct causative mechanisms.

Legislation: the clinical onset of this condition was on 18 May 2010, after 1 July 2004, during continuous full-time service. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim and the Statements of Principles apply. The Reasonable Hypothesis instrument applies to the veteran's warlike service in Afghanistan in 2007, where the fragment wound damaged the right great saphenous vein valve, and in the Middle East in 2009, where the left ankle fracture led to deep vein thrombosis, iliac vein obstruction and pulmonary hypertension, and where she stood for long field kitchen shifts. The Balance of Probabilities instrument applies to peacetime service, including her years of standing in garrison kitchens before onset and before the worsening.

Each factor must be related to the person's relevant service. Under the beneficial approach required by the legislation, the absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.

Balance of Probabilities — Statement of Principles concerning Chronic Venous Insufficiency of the Lower Limb and Varicose Veins of the Lower Limb, No. 8 of 2021

Causative factors

Factor 9(1): having deep vein thrombosis within a deep vein that drains the affected lower limb before the clinical onset of chronic venous insufficiency of the lower limb or varicose veins of the lower limb; — MET

- Duplex ultrasound on 27 November 2009 confirmed occlusive thrombus in the left common femoral, femoral and popliteal veins, deep veins draining the left leg, after a service ankle fracture and immobilisation in a cast. This was about six months before the onset of varicose veins on 18 May 2010. The thrombus damaged the deep vein valves, shown as post-thrombotic reflux on 03 June 2010.

Factor 9(2): having chronic complete or partial obstruction of a vein that drains the affected lower limb before the clinical onset of chronic venous insufficiency of the lower limb or varicose veins of the lower limb; — MET

- CT venography on 24 February 2010 showed chronic post-thrombotic narrowing of the left common iliac vein of about 70 per cent, a partial obstruction of a vein draining the left leg, with collateral varices. It followed the service-related thrombosis of November 2009 and was present before onset on 18 May 2010.

Factor 9(3): being pregnant at the time of the clinical onset of chronic venous insufficiency of the lower limb or varicose veins of the lower limb; — MET

- Pregnancy was confirmed on 30 March 2010, and the veteran was about 16 weeks pregnant on 18 May 2010, when the varicose veins appeared. She continued full kitchen duties standing for 8 to 10 hours a day during the pregnancy, as required by her employment.

Factor 9(4): standing for at least four hours per day, on more days than not, for a continuous period of at least the five years before the clinical onset of chronic venous insufficiency of the lower limb or varicose veins of the lower limb; — MET

- From 18 May 2005 to 18 May 2010 the veteran worked as an Army cook in garrison kitchens, standing for 8 to 12 hours a day on most working days, apart from about ten weeks in a cast from November 2009. Over this continuous five-year period she stood for at least four hours a day on more days than not, as a requirement of her trade.

Factor 9(5): having chronic dysfunction of the calf muscle pump in the affected lower limb at the time of the clinical onset of chronic venous insufficiency of the lower limb or varicose veins of the lower limb; — MET

- The trimalleolar fracture of the left ankle sustained on duty on 20 November 2009 healed with marked stiffness, with dorsiflexion limited to 0 degrees on 24 February 2010. A stiff ankle prevents the calf muscles from emptying the deep veins with walking. This chronic calf muscle pump dysfunction was present at onset on 18 May 2010.

Factor 9(6): having an acquired arteriovenous fistula involving the blood vessels that supply the affected lower limb at the time of the clinical onset of chronic venous insufficiency of the lower limb or varicose veins of the lower limb; — MET

- Right heart catheterisation via the right femoral vein on 10 March 2010, performed to investigate pulmonary hypertension arising from the service-related pulmonary emboli, caused a right common femoral arteriovenous fistula, confirmed on duplex on 22 March 2010. Arterialised flow into the femoral vein raised venous pressure in the right leg, and the fistula was present at onset on 18 May 2010.

Factor 9(7): having trauma to a valve in a vein of the affected lower limb causing dysfunction or incompetence of that valve before the clinical onset of chronic venous insufficiency of the lower limb or varicose veins of the lower limb; — MET

- On 12 May 2007 a rocket fragment lacerated the right great saphenous vein near the saphenofemoral junction, and the operating surgeon recorded damage to its terminal valve. Duplex on 03 June 2010 showed the scarred terminal valve to be incompetent. The trauma occurred three years before onset and arose from her service.

Factor 9(8): having tricuspid valve regurgitation, in the presence of a pulsatile greater saphenous vein, at the time of the clinical onset of chronic venous insufficiency of the lower limb or varicose veins of the lower limb; — MET

- Echocardiography on 24 February 2010 showed moderate tricuspid regurgitation from pulmonary hypertension following the service-related pulmonary emboli. A visibly pulsatile right great saphenous vein was recorded on 25 May 2010 and confirmed on duplex on 03 June 2010. Both were present at onset on 18 May 2010.

Factor 9(9)(a): for chronic venous insufficiency of the lower limb only: having varicose veins of the affected lower limb at the time of the clinical onset of chronic venous insufficiency of the lower limb; — MET

- Chronic venous insufficiency was diagnosed on 18 March 2013. The veteran had had varicose veins of both legs since 18 May 2010, and they were present when the chronic venous insufficiency began.

Factor 9(9)(b): for chronic venous insufficiency of the lower limb only: having heart failure at the time of the clinical onset of chronic venous insufficiency of the lower limb; — MET

- Right heart failure from chronic thromboembolic pulmonary hypertension was diagnosed on 02 March 2013, with a dilated right ventricle and peripheral oedema, and diuretics were commenced. It was present at the onset of chronic venous insufficiency on 18 March 2013.

Factor 9(9)(c): for chronic venous insufficiency of the lower limb only: being obese at the time of the clinical onset of chronic venous insufficiency of the lower limb; — MET

- The veteran's BMI was 33.4 on 18 March 2013, the date chronic venous insufficiency was diagnosed. Her weight had increased with reduced exercise tolerance from the service-related pulmonary hypertension and the stiff left ankle.

Factor 9(10): for varicose veins of the thigh only, having a varicosity of an abdominal or pelvic vein, leading to reflux into the affected thigh vein via interconnecting or collateral veins, at the time of the clinical onset of varicose veins of the thigh; — MET

- CT venography on 24 February 2010 showed pelvic and vulval collateral varices that developed around the obstructed left common iliac vein, and duplex on 03 June 2010 showed reflux from these pelvic varices into the left posterior thigh veins. The pelvic varicosity was present when the thigh varicose veins appeared on 18 May 2010.

Worsening factors

Factor 9(11): having deep vein thrombosis within a deep vein that drains the affected lower limb before the clinical worsening of chronic venous insufficiency of the lower limb or varicose veins of the lower limb; — MET

- In addition to the left femoral and popliteal thrombosis of November 2009, the veteran had a recurrent left calf deep vein thrombosis on 02 February 2016, four months before the documented worsening on 14 June 2016. Duplex on 14 June 2016 showed recanalising calf vein thrombus and increased deep venous reflux.

Factor 9(12): having chronic complete or partial obstruction of a vein that drains the affected lower limb before the clinical worsening of chronic venous insufficiency of the lower limb or varicose veins of the lower limb; — MET

- The post-thrombotic narrowing of the left common iliac vein, shown in February 2010, persisted and was present before the worsening on 14 June 2016.

Factor 9(13): being pregnant at the time of the clinical worsening of chronic venous insufficiency of the lower limb or varicose veins of the lower limb; — MET

- The veteran was 22 weeks pregnant on 14 June 2016, when enlarging varicose veins and a venous ulcer were documented. She was working full time as a senior cook during the pregnancy.

Factor 9(14): standing for at least four hours per day, on more days than not, for a continuous period of at least the five years before the clinical worsening of chronic venous insufficiency of the lower limb or varicose veins of the lower limb; — MET

- From 14 June 2011 to 14 June 2016 the veteran worked full time as a senior cook in a garrison kitchen, standing for 7 to 10 hours on most working days, having returned from maternity leave on 10 January 2011. Over this continuous five-year period she stood for at least four hours a day on more days than not.

Factor 9(15): having chronic dysfunction of the calf muscle pump in the affected lower limb at the time of the clinical worsening of chronic venous insufficiency of the lower limb or varicose veins of the lower limb; — MET

- The left ankle remained stiff, with dorsiflexion of 5 degrees, at the worsening on 14 June 2016, impairing the calf muscle pump in the left leg where the venous ulcer developed.

Factor 9(16): having an acquired arteriovenous fistula involving the blood vessels that supply the affected lower limb at the time of the clinical worsening of chronic venous insufficiency of the lower limb or varicose veins of the lower limb; — MET

- The right common femoral arteriovenous fistula, managed conservatively, persisted and was present on duplex at the worsening on 14 June 2016.

Factor 9(17): having trauma to a valve in a vein of the affected lower limb causing dysfunction or incompetence of that valve before the clinical worsening of chronic venous insufficiency of the lower limb or varicose veins of the lower limb; — MET

- The traumatic incompetence of the right great saphenous terminal valve from the fragment wound of 12 May 2007 preceded the worsening on 14 June 2016 and remained incompetent on duplex at that date.

Factor 9(18): having tricuspid valve regurgitation, in the presence of a pulsatile greater saphenous vein, at the time of the clinical worsening of chronic venous insufficiency of the lower limb or varicose veins of the lower limb; — MET

- Echocardiography in May 2016 showed moderate to severe tricuspid regurgitation, and the right great saphenous vein remained pulsatile on duplex on 14 June 2016, at the worsening.

Factor 9(19)(a): for chronic venous insufficiency of the lower limb only: having varicose veins of the affected lower limb at the time of the clinical worsening of chronic venous insufficiency of the lower limb; — MET

- Enlarging varicose veins of both legs were present when the chronic venous insufficiency worsened to venous ulceration on 14 June 2016.

Factor 9(19)(b): for chronic venous insufficiency of the lower limb only: having heart failure at the time of the clinical worsening of chronic venous insufficiency of the lower limb; — MET

- Right heart failure, treated with diuretics since March 2013, was present at the worsening on 14 June 2016.

Factor 9(19)(c): for chronic venous insufficiency of the lower limb only: being obese at the time of the clinical worsening of chronic venous insufficiency of the lower limb; — MET

- The veteran's BMI before her second pregnancy was 35.1, and she remained obese at the worsening on 14 June 2016.

Factor 9(20): for varicose veins of the thigh only, having a varicosity of an abdominal or pelvic vein, leading to reflux into the affected thigh vein via interconnecting or collateral veins, at the time of the clinical worsening of varicose veins of the thigh; — MET

- Pelvic and vulval varices with reflux into the left posterior thigh veins persisted and enlarged during the second pregnancy, and were present when the thigh varicosities worsened on 14 June 2016.

Factor 9(21): inability to obtain appropriate clinical management for chronic venous insufficiency of the lower limb or varicose veins of the lower limb. — MET

- The veteran was referred to a vascular surgeon on 25 May 2010 but was not seen until July 2011, 14 months later, because she was posted to a regional base without visiting vascular services. Medical-grade compression stockings were not supplied until 2011, and she continued standing duties without them. Under Brew v Repatriation Commission (1999), this is an inability to obtain appropriate clinical management, and her veins enlarged and her skin changes progressed during the delay.

Reasonable Hypothesis — Statement of Principles concerning Chronic Venous Insufficiency of the Lower Limb and Varicose Veins of the Lower Limb, No. 7 of 2021

Causative factors

Factor 9(1): having deep vein thrombosis within a deep vein that drains the affected lower limb before the clinical onset of chronic venous insufficiency of the lower limb or varicose veins of the lower limb; — MET

- The left femoral and popliteal deep vein thrombosis of 27 November 2009 followed a trimalleolar ankle fracture sustained on warlike service in the Middle East on 20 November 2009, immobilisation in a cast and a 24-hour aeromedical evacuation flight. It occurred about six months before onset on 18 May 2010.

Factor 9(2): having chronic complete or partial obstruction of a vein that drains the affected lower limb before the clinical onset of chronic venous insufficiency of the lower limb or varicose veins of the lower limb; — MET

- The chronic partial obstruction of the left common iliac vein shown on 24 February 2010 resulted from the deep vein thrombosis that followed her injury on warlike service, and was present before onset on 18 May 2010.

Factor 9(3): being pregnant at the time of the clinical onset of chronic venous insufficiency of the lower limb or varicose veins of the lower limb; — MET

- The veteran was about 16 weeks pregnant on 18 May 2010. The pregnancy acted on leg veins already damaged by the fragment wound sustained in Afghanistan and the thrombosis that followed her injury in the Middle East, and the veins appeared during the pregnancy.

Factor 9(4): standing for at least four hours per day, on more days than not, for a continuous period of at least the five years before the clinical onset of chronic venous insufficiency of the lower limb or varicose veins of the lower limb; — MET

- The five years before onset, from 18 May 2005 to 18 May 2010, included warlike service in Afghanistan from 01 February 2007 to 15 August 2007 and in the Middle East from 10 June 2009 to 24 November 2009, during which she stood for 12 to 14 hours a day in deployed field kitchens. With her garrison kitchen duties either side, she stood for at least four hours a day on more days than not throughout the period.

Factor 9(5): having chronic dysfunction of the calf muscle pump in the affected lower limb at the time of the clinical onset of chronic venous insufficiency of the lower limb or varicose veins of the lower limb; — MET

- The left ankle fracture sustained on warlike service in the Middle East on 20 November 2009 left the ankle stiff, with no dorsiflexion beyond neutral, impairing the left calf muscle pump. This was present at onset on 18 May 2010.

Factor 9(6): being obese at the time of the clinical onset of chronic venous insufficiency of the lower limb or varicose veins of the lower limb; — MET

- The veteran's pre-pregnancy weight was 88 kg at a height of 1.66 m, a BMI of 31.9, recorded on 25 May 2010, and her BMI was 31.2 on her pre-deployment examination of 15 April 2009 before warlike service. She was obese at onset on 18 May 2010.

Factor 9(7): having an acquired arteriovenous fistula involving the blood vessels that supply the affected lower limb at the time of the clinical onset of chronic venous insufficiency of the lower limb or varicose veins of the lower limb; — MET

- The right common femoral arteriovenous fistula was caused on 10 March 2010 by catheterisation to investigate pulmonary hypertension resulting from pulmonary emboli that followed her injury on warlike service. It was present at onset on 18 May 2010.

Factor 9(8): having trauma to a valve in a vein of the affected lower limb causing dysfunction or incompetence of that valve before the clinical onset of chronic venous insufficiency of the lower limb or varicose veins of the lower limb; — MET

- On warlike service in Afghanistan on 12 May 2007 a rocket fragment lacerated the right great saphenous vein and damaged its terminal valve, which was incompetent on duplex on 03 June 2010. The trauma occurred before onset on 18 May 2010.

Factor 9(9): having tricuspid valve regurgitation, in the presence of a pulsatile greater saphenous vein, at the time of the clinical onset of chronic venous insufficiency of the lower limb or varicose veins of the lower limb; — MET

- Moderate tricuspid regurgitation from pulmonary hypertension, a consequence of the pulmonary emboli that followed her injury on warlike service, was shown on 24 February 2010, and the right great saphenous vein was pulsatile on 25 May 2010. Both were present at onset on 18 May 2010.

Factor 9(10)(a): for chronic venous insufficiency of the lower limb only: having varicose veins of the affected lower limb at the time of the clinical onset of chronic venous insufficiency of the lower limb; — MET

- Bilateral varicose veins, present since 18 May 2010, were present at the onset of chronic venous insufficiency on 18 March 2013.

Factor 9(10)(b): for chronic venous insufficiency of the lower limb only: having heart failure at the time of the clinical onset of chronic venous insufficiency of the lower limb; — MET

- Right heart failure from pulmonary hypertension, which followed pulmonary emboli after her injury on warlike service in 2009, was diagnosed on 02 March 2013 and was present at the onset of chronic venous insufficiency on 18 March 2013.

Factor 9(11): for varicose veins of the thigh only, having a varicosity of an abdominal or pelvic vein, leading to reflux into the affected thigh vein via interconnecting or collateral veins, at the time of the clinical onset of varicose veins of the thigh; — MET

- Pelvic collateral varices formed around the left common iliac vein obstruction that followed her injury on warlike service, and duplex on 03 June 2010 showed reflux from them into the left posterior thigh veins. They were present when the thigh varicose veins appeared on 18 May 2010.

Worsening factors

Factor 9(12): having deep vein thrombosis within a deep vein that drains the affected lower limb before the clinical worsening of chronic venous insufficiency of the lower limb or varicose veins of the lower limb; — MET

- The left femoral and popliteal thrombosis of November 2009, following her injury on warlike service, and the recurrent left calf thrombosis of 02 February 2016 both occurred before the worsening on 14 June 2016.

Factor 9(13): having chronic complete or partial obstruction of a vein that drains the affected lower limb before the clinical worsening of chronic venous insufficiency of the lower limb or varicose veins of the lower limb; — MET

- The post-thrombotic left common iliac vein obstruction arising from her warlike service persisted and was present before the worsening on 14 June 2016.

Factor 9(14): being pregnant at the time of the clinical worsening of chronic venous insufficiency of the lower limb or varicose veins of the lower limb; — MET

- The veteran was 22 weeks pregnant at the worsening on 14 June 2016, acting on veins damaged by her injuries on warlike service in 2007 and 2009.

Factor 9(15): standing for at least four hours per day, on more days than not, for a continuous period of at least the five years before the clinical worsening of chronic venous insufficiency of the lower limb or varicose veins of the lower limb; — MET

- From 14 June 2011 to 14 June 2016 the veteran stood for 7 to 10 hours on most working days as a senior cook, with veins already damaged on warlike service, and so stood for at least four hours a day on more days than not throughout the five years before the worsening.

Factor 9(16): having chronic dysfunction of the calf muscle pump in the affected lower limb at the time of the clinical worsening of chronic venous insufficiency of the lower limb or varicose veins of the lower limb; — MET

- The stiff left ankle from the fracture sustained on warlike service in 2009 continued to impair the calf muscle pump at the worsening on 14 June 2016, when a venous ulcer developed above the left ankle.

Factor 9(17): being obese at the time of the clinical worsening of chronic venous insufficiency of the lower limb or varicose veins of the lower limb; — MET

- The veteran's BMI was 35.1 before her second pregnancy and she was obese at the worsening on 14 June 2016. Her weight gain followed reduced activity from the stiff ankle and pulmonary hypertension arising from her warlike service.

Factor 9(18): having an acquired arteriovenous fistula involving the blood vessels that supply the affected lower limb at the time of the clinical worsening of chronic venous insufficiency of the lower limb or varicose veins of the lower limb; — MET

- The right common femoral arteriovenous fistula, caused by investigation of pulmonary hypertension arising from her warlike service, was present at the worsening on 14 June 2016.

Factor 9(19): having trauma to a valve in a vein of the affected lower limb causing dysfunction or incompetence of that valve before the clinical worsening of chronic venous insufficiency of the lower limb or varicose veins of the lower limb; — MET

- The traumatic incompetence of the right great saphenous terminal valve from the fragment wound on warlike service in Afghanistan on 12 May 2007 preceded the worsening on 14 June 2016.

Factor 9(20): having tricuspid valve regurgitation, in the presence of a pulsatile greater saphenous vein, at the time of the clinical worsening of chronic venous insufficiency of the lower limb or varicose veins of the lower limb; — MET

- Moderate to severe tricuspid regurgitation was shown in May 2016 and the right great saphenous vein remained pulsatile on 14 June 2016, at the worsening. The regurgitation resulted from pulmonary hypertension following her warlike service injury.

Factor 9(21)(a): for chronic venous insufficiency of the lower limb only: having varicose veins of the affected lower limb at the time of the clinical worsening of chronic venous insufficiency of the lower limb; — MET

- Bilateral varicose veins were present and enlarging when the chronic venous insufficiency worsened to ulceration on 14 June 2016.

Factor 9(21)(b): for chronic venous insufficiency of the lower limb only: having heart failure at the time of the clinical worsening of chronic venous insufficiency of the lower limb; — MET

- Right heart failure arising from pulmonary hypertension after her warlike service injury was present at the worsening on 14 June 2016.

Factor 9(22): for varicose veins of the thigh only, having a varicosity of an abdominal or pelvic vein, leading to reflux into the affected thigh vein via interconnecting or collateral veins, at the time of the clinical worsening of varicose veins of the thigh; — MET

- The pelvic collateral varices around the iliac vein obstruction arising from her warlike service continued to reflux into the left thigh veins and were present when the thigh varicosities worsened on 14 June 2016.

Factor 9(23): inability to obtain appropriate clinical management for chronic venous insufficiency of the lower limb or varicose veins of the lower limb. — MET

- During her warlike service in the Middle East in 2009 no compression garments or prophylaxis against thrombosis were provided before or during the aeromedical evacuation flight with her leg in a cast, and after onset her vascular referral of 25 May 2010 was not actioned for 14 months. Under Brew v Repatriation Commission (1999), these service circumstances amount to an inability to obtain appropriate clinical management, and her varicose veins and skin changes progressed during the delay.

The % contribution of the causes is 100% and significant.

Sequelae

The varicose veins have led to chronic venous insufficiency with lipodermatosclerosis and venous eczema of the left leg, recurrent venous ulceration above the left medial malleolus, and superficial thrombophlebitis of the right great saphenous vein in 2017. Each of these is a sequela of the accepted condition and may be claimed in its own right.

Unintended Consequence

Met. The right common femoral arteriovenous fistula that raised venous pressure in the right leg is an unintended consequence of the right heart catheterisation performed on 10 March 2010 by specialists funded by the Commonwealth to investigate her service-related pulmonary hypertension (section 6A of the DRCA and the equivalent provisions of the MRCA).

Inability to Attain Appropriate Medical Management

MET. No compression stockings or thromboprophylaxis were provided for the 24-hour aeromedical evacuation flight on 24 November 2009 with the veteran's leg in a cast after an injury on warlike service, and she developed deep vein thrombosis three days later. After onset, her referral to a vascular surgeon on 25 May 2010 was not actioned for 14 months because she was posted to a regional base without vascular services, and medical-grade compression stockings were not supplied until 2011 while she continued standing duties. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), the circumstances of her service prevented her from obtaining the preventive and specialist care that was clinically appropriate, and that inability contributed to the onset and progression of her varicose veins and chronic venous insufficiency.

5. Please provide a Health Summary and a medication / prescribing history.

See attached report.

References

1. 12 May 2007, Operation report, wound exploration and vein repair, Surgeon, Role 3 hospital, Afghanistan
2. 15 Apr 2009, Pre-deployment medical examination, Medical Officer
3. 20 Nov 2009, Casualty treatment record and X-ray report, Medical Officer, Middle East
4. 27 Nov 2009, Duplex ultrasound and CT pulmonary angiogram reports, Radiologist
5. 24 Feb 2010, CT venogram and echocardiogram reports, Radiologist and Cardiologist
6. 10 Mar 2010, Right heart catheterisation report, Cardiologist
7. 22 Mar 2010, Duplex ultrasound right groin report, Vascular sonographer
8. 25 May 2010, Outpatient health record and referral, Medical Officer, Garrison health centre
9. 03 Jun 2010, Venous duplex ultrasound report, Vascular sonographer
10. 02 Mar 2013, Specialist consultation, Respiratory physician
11. 18 Mar 2013, Outpatient health record, Medical Officer, Garrison health centre
12. 02 Feb 2016, Duplex ultrasound report, Radiologist
13. 14 Jun 2016, Venous duplex ultrasound and specialist consultation, Vascular surgeon
14. Statement of Principles concerning Chronic Venous Insufficiency of the Lower Limb and Varicose Veins of the Lower Limb (Balance of Probabilities) No. 8 of 2021, Repatriation Medical Authority
15. Statement of Principles concerning Chronic Venous Insufficiency of the Lower Limb and Varicose Veins of the Lower Limb (Reasonable Hypothesis) No. 7 of 2021, Repatriation Medical Authority