Purpose To assess the safety, efficacy, and clinical outcomes of transjugular intrahepatic portosystemic shunt (TIPS) creation for treatment of medically refractory ascites. Materials and Methods In this single institution retrospective study, 65 patients (M:F=43:22, mean age 55 years, mean Child-Pugh score 9.9, mean Model for End Stage Liver Disease or MELD score 15.2) who underwent elective TIPS creation for refractory ascites between 1999-2012 were selected for analysis. Medical record review was used to identify demographic (age, gender), liver disease (Child-Pugh, MELD score), procedure (indication, urgency, stent type, portosystemic gradient or PSG reduction), and outcome (3-month pre- and post- procedure frequency of paracenteses, complications) data, and the influence of these parameters on 30- and 90-day mortality was assessed using multivariate analysis of variance. Results TIPS were successfully created using Wallstents (n=8) or Viatorr covered stent-grafts (n=57). Hemodynamic success was achieved in all cases. Mean PSG reduction was 13.5 mm Hg, and mean final PSG was 7.1 mm Hg. Complications at 30-days included encephalopathy (22/65, 33.9%) and liver failure (2/65, 3.1%). 30- and 90-day mortality rates were 7.7% (5/65) and 15.4% (10/65). Clinical improvement in ascites occurred in 78.5% (51/65) of patients. At 3-month follow-up, the need for paracentesis was completely eliminated in 32.3% (21/65), while the frequency of paracenteses was reduced by ≥50% in 32.3% (21/65) and by ≤50% in 13.9% (9/65). No change in ascites occurred in 9.2% (6/65), and 13.9% (9/65) required more frequent paracenteses. No PSG threshold was identified as most optimal for ascites reduction. Child-Pugh and MELD scores were significantly associated with 30- (P=0.001, 0.036) and 90-day (P=0.001, 0.004) mortality. No other parameters showed a statistically significant relationship with survival. Conclusion TIPS is a safe and effective procedure to treat medically refractory ascites, eliminating or reducing the need for paracenteses in 80% of cases within 3-months. While the rate of hepatic encephalopathy is non-trivial, these results further validate TIPS creation in this setting.