Although a survival benefit following transjugular intrahepatic portosystemic shunt (TIPS) creation for variceal bleeding [1] and ascites [2,3] has been reported in randomized controlled trials (RCTs) in cirrhotic patients, clinical outcomes after TIPS placement in patients with late-stage liver disease and high Model for End-Stage Liver Disease (MELD) scores remain controversial. The MELD score was originally created to predict the survival after TIPS placement in patients with cirrhosis; by intention, a high MELD score predicts poor survival after TIPS [4]. While the RCTs supported early TIPS placement for variceal bleeding and favored TIPS over repeated large-volume paracentesis in patients with Child-Pugh scores up to 11 or 13, the investigators intentionally excluded patients with severely compromised liver function and higher scores. The RCTs also did not report on outcomes relative to the MELD scores.Consequently, data regarding TIPS outcomes in patients with high MELD scores have historically been derived from non-randomized studies. Angermayr et al. [5] reported a 60% 1-year mortality rate in patients with MELD [ 18. Ferral et al. [6] reported a 90-day mortality rate of 34.8% in patients after elective TIPS with MELD scores of 18-24 and 65.5% in patients with MELD C 18, yielding a 90-day mortality of 44% for all patients with MELD C 18. Casadaban et al. [7] stated that survival rates after emergent TIPS placement for acute variceal bleeding were predicted by MELD scores and were inferior to survival rates reported in the elective TIPS placement population, with a 90-day mortality rate of 36% for MELD 19-25 and 83% for MELD C 26.The high post-TIPS mortality rates reported in patients with high MELD scores have led some to conclude that TIPS procedures should not be performed in those patients, particularly if the MELD is [25 [6]. Although such a conclusion implies that TIPS placement is harmful, or at least, not beneficial to that subset of patients, this assumption remains conjectural. The prognosis of patients with high MELD scores is generally poor, with reported 1-year mortality of approximately 30% for MELD scores between 20 and 29 and approximately 60% for MELD scores C30 [8]. Given the variability among patient cohorts in how MELD scores are stratified, and in how survival outcomes are reported, and given the similarities in the reported survival statistics for high-MELD patients with and without TIPS, it is difficult to isolate the effect of TIPS placement from the overall dismal survival typical of high-MELD patients.In this issue of Digestive Diseases and Sciences, Ascha et al. [9] have taken a step toward answering the question of whether TIPS placement increases or decreases survival in patients with high MELD scores. They retrospectively analyzed a cohort of 144 patients with MELD score C15 who underwent TIPS procedures, matched them by MELD score and age to 144 patients who had not undergone TIPS procedures, excluding patients with hepatocellular carcinoma or those who died within 48 h of ...