The Transjugular Intrahepatic Portosystemic Shunt (TIPS) has now become an accepted part of the therapeutic armory available to the practicing clinician. It may stop variceal bleeding when traditional endoscopic techniques have failed, and can be used as secondary prevention of variceal bleeding, as well as a treatment for intractable ascites and the Budd-Chiari syndrome. It has afforded new insights into the mechanisms of these disorders and significantly advanced our knowledge of disease pathophysiology. It has done all these things, and yet is a procedure that may be performed without interrupting the surgical field, should the patient require a transplant at a later date. In this article, the various indications for TIPS are reviewed with a critical eye. Advances in placement technique, refinement of indications, and results are all discussed. The authors present an up-to-date assessment of the clinical trials performed using this radiologic shunt, as well as their conclusions regarding the various clinical indications.