The use of the use of the transjugular intrahepatic portosystemic shunt (TIPS) and its indication for treatment of the various symptoms of portal hypertension is till under debate. This paper presents guidelines for its application based on randomized studies, case reports, and own experience. TIPS is indicated in acute variceal bleeding not responding to endoscopic treatment and medication. In this emergency situation TIPS has probably a lower early mortality rate than surgical shunts. The prophylactic treatment of first variceal bleeding is a domain for medical therapy. Due to its increased incidence of hepatic encephalopathy TIPS may only be indicated in very selected cases with a high risk of bleeding and associated severe complications. Five randomized trials including 402 patients exist comparing endoscopic treatment and TIPS. Except one study the results are conclusive demonstrating comparable survival of the groups. Despite these results, in view of the high rate of shunt-induced encephalopathy with its negative effect on life quality, TIPS may better be a secondary treatment as long as studies on life quality are lacking. However, im many patients additional complications, e.g., accompanying ascites or intolerance to bleedings, may justify the primary use of TIPS. TIPS is also effective in the treatment of refractory ascites. Conclusive randomized studies are not available, therefore, TIPS should be restricted to patients who are intolerant to or who fail paracentesis. In addition to the leading indications mentioned, rare indications for TIPS and the role of surgical shunts are discussed.