This study states that Whether endovascular aortic repair (EVAR) represents a suitable alternative to open surgery for patients with cirrhosis remains to be established, because it entails the risk of severe coagulopathy-related complications,5 including disseminated intravascular coagulation, and the onset of endoleaks and endotension at midterm follow-up requiring surgical conversion. Thus, the article by Zettervall et al,1 although commendable for the large number of patients considered in the reported analyses, has the limitation of focusing on the 30-day outcomes, overlooking the mid- and long-term results of EVAR. Consequently, until or unless the durability of EVAR in patients with cirrhosis will be established, we believe that increasing the AAA size threshold for EVAR to >6 cm for patients with a MELD score >10, as suggested by the Zettervall et al,1 does not adequately address the issue of the indications for treatment in these patients.

We believe that patients with cirrhosis with a MELD score of ≥10 should not be treated if they can survive surgery or EVAR but only if such treatment can provide them with acceptable midterm survival.

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