Ascites becomes refractory to medical treatmentin nearly 10% of cirrhotic patients, who then requirerepeated large-volume paracentesis. In this prospectivestudy we evaluated the use of transjugular intrahepatic portosystemic shunt (TIPS) in 30 patients withrefractory ascites. TIPS was successful in all andresulted in a 54% reduction in portacaval gradient (from22.8 ± 0.8 to 10.4 ± 0.6 mm Hg). Ascitesbecame easily controlled with diuretics in 26 patientsfollowing TIPS. Ascites recurrence associated with shuntstenosis was observed during follow-up in eightpatients; revision could be undertaken in five of themand resulted in good control of ascites. Inresponders, a marked decrease in plasma aldosterone andrenin activity, a reduction in serum creatinine, and arise in urinary sodium excretion were observed.Creatinine and inulin clearances improved significantly;PAH clearance remained unchanged. However, new-onset orworsening hepatic encephalopathy was seen in 14patients. Severe disabling chronic encephalopathyoccurred in five patients; it could be reversedsuccessfully by balloon occlusion of the shunt in three.The cumulative survival rate was 41 and 34% at 1 and 2years, respectively. In summary, TIPS can controlrefractory ascites in a majority of patients but isassociated with a high rate of chronic disabling HE. Inaddition, the survival rate is poor. Randomized trialsare needed to evaluate the exact role of TIPS in the management of refractory ascites. It isunlikely to improve survival but can ameliorate qualityof life in nontransplant candidates and be useful as abridge to transplantation, in particular, to improve denutrition associated with longstanding tenseascites.