Is transjugular intrahepatic portosystemic shunt (TIPS) preferable to a surgical shunting procedure in patients who are expected to benefit from a portal-systemic shunt? Since randomized trials comparing these procedures have not yet been reported, we attempted to define the present best therapeutic strategy by reviewing both the recent literature on TIPS and surgical shunting and our first experience with TIPS. The results suggest that TIPS is just as effective as surgical shunting but is associated with a lower morbidity and mortality. Procedure related deaths seem rare. In our series of 16 patients there was one death within 30 days. Seven early complications including stent dislodgement, early occlusion, encephalopathy and haemolysis were noted. The incidence of long-term complications, especially encephalopathy and shunt occlusion, seems comparable for both shunting procedures. Major advantages of TIPS are its therapeutic efficacy in patients with ascites and the fact that the technical difficulties of performing liver transplantation are not increased. We conclude that TIPS, performed by an experienced team, is at present the procedure of choice in patients who are candidates for a portal-systemic shunt, especially in patients in whom liver transplantation is a future option. Surgical shunts can be reserved for patients in whom TIPS is not feasible or has failed.