Implantation of a transjugular intrahepatic portosystemic shunt (TIPS) is associated with a broad spectrum of acute and chronic complications. Data concerning incidence and prognosis of these complications are conflicting but of great importance toward defining the role of TIPS relative to other therapeutic options. We conducted a prospective, uncontrolled cohort study in 53 patients to assess incidence, management and clinical outcome of complications occurring after TIPS procedure. Mean follow-up was 21.1 +/- 9.0 months. Technique-related mortality was 2%; 9% of patients died within 30 days after TIPS procedure. The overall survival rate after 18 months was 74%. The overall incidence of primary hepatic encephalopathy (HE) within the first year was 25%, and 77% of episodes could be managed successfully by medical treatment or implantation of a reducing stent. The rate of patients without rebleeding after 18 months was 84%. Rebleeding was associated with shunt abnormalities, and the bleeding was controlled by revision of the stent. Two patients died of variceal hemorrhage. The cumulative incidence of shunt stenosis or occlusion was 47% after 18 months. The technical success rate of shunt revision was 97%. TIPS implantation is associated with a considerable risk of HE and shunt stenosis or occlusion. Nevertheless most episodes of HE can be managed by medical treatment or implantation of a reducing stent. Angiographic revision of the stent is successful in nearly all cases of stenosis or occlusion. We therefore conclude that TIPS implantation in combination with careful follow-up examinations constitutes effective medium-term treatment of portal hypertension in a considerable proportion of patients.