Decompressive portosystemic shunts play a significant role in the treatment of patients with portal hypertension and gastroesophageal varices. The main indication for portal shunting procedures is the prevention of recurrent variceal bleeding in patients with cirrhosis and portal hypertension after failure of endoscopic sclerotherapy. Portal shunting procedures are not indicated for prophylaxis against variceal bleeding in patients who have not yet bled. The ideal candidates for shunt procedures are patients at Child's class A or B risk levels who have favorable venous anatomy. The procedures themselves can be divided into two main categories:

Total shunts

With total shunts, the entire portal venous blood flow is shunted into the systemic venous circulation. This includes end-to-side and side-to-side portacaval shunts, central splenorenal shunts, Marion–Clatworthy mesocaval shunts, interposition mesocaval shunts, and the recently introduced transjugular intrahepatic portosystemic shunt (TIPS). The small graft portacaval interposition shunt is a modification designed to achieve partial rather than total diversion of portal venous flow.

Selective distal splenorenal (Warren) shunt

With the selective distal splenorenal shunt, the gastroesophageal varices are selectively decompressed by way of the upper stomach through the short gastric veins and the disconnected splenic vein into the left renal vein, while enough pressure is maintained in the portal and superior mesenteric veins to drive blood through the diseased liver. The spleen is not removed in this procedure.

Because it is associated with a lower incidence of encephalopathy and hepatic insufficiency, the distal splenorenal shunt is used in most patients.