Variceal rebleeding after portosystemic shunting. Strategies and solutions to a vexing problem. The purpose of this review was to discuss an approach to the treatment of recurrent bleeding from esophageal or gastric varices after portosystemic shunt. From our own clinical experience, as well as that of others, it appears that re-establishment of portal decompression should offer the best chance at long-term survival. Luckily, innovations in angiographic technique have allowed attainment of this goal without the inordinate risk of an operative procedure. However, not all patients' situations will be amenable to such treatment. For some of them, operative decompression of the portal venous system can be carried out in an anatomic area previously untouched. For those patients in whom no decompression is possible, direct endoscopic treatment of the varices will offer an alternative, albeit temporizing, approach. 