Successful percutaneous balloon dilatations of four mesocaval shunts (one stenosis, three occlusions) and one acutely thrombosed portocaval shunt were performed in four patients with massive esophageal variceal bleeding. Shunt failure was acute (1-2 days) in two patients and delayed (1-2 years) in three. One patient died early in hepatic failure. Portocaval pressure gradients became normal in four patients and have been kept in the 11-16 cm H2O range by careful outpatient shunt pressure monitoring and, if indicated, redilatation at 6 months' interval. Transanastomotic coil occlusion of large esophageal varices was done in three patients. There has been no recurrent variceal bleeding in the four surviving patients over a period of 16 months.