The transjugular intrahepatic portacaval shunt (TIPS) is a novel angiographic method for achieving portal decompression without operation. Fiftynine consecutive patients underwent a total of 80 consecutive TIPS procedures. The procedure was unsuccessful in 4 patients (7%) and initially succeeded in 55 (93%). Eighteen patients (30%) underwent 2 or more TIPS procedures during the same hospitalization due to technical difficulties, early rebleeding, shunt stenosis, or thrombosis. Early TIPS occlusion occurred in seven patients (12%) and led to recurrent variceal hemorrhage in five. Forty-two percent of the cases of persisting or recurrent bleeding were nonvariceal. Procedure-related complications occurred in 10% of TIPS procedures or 14% of patients. Twenty-three patients (39%) were actively bleeding at the time of the procedure, and, in 6 of these (26%), bleeding was never controlled. In-hospital mortality (25%) was related only to the presence of bleeding at the time of TIPS (56% for emergent versus 5.5% for nonemergent, p<0.0001). Mortality was not related to the Child-Pugh classification. Hemodynamic stabilization, vasoconstrictor therapy, balloon tamponade, and sclerotherapy were underutilized in 30% to 40% of patients prior to TIPS. Aggressive medical management should be used to stop variceal hemorrhage prior to TIPS in all patients, regardless of the Child-Pugh classification. Prospective trials comparing TIPS with sclerotherapy and surgical shunt are required to demonstrate the proper role of this procedure in the management of portal hypertension and variceal hemorrhage.