The pathophysiology of the hyperdynamic circulation in cirrhosis may be related to chronic nitric oxide synthesis induced by endotoxemia. This has potential therapeutic implications, but the maintenance of vasodilatation may be important for tissue perfusion. β-Blockers are the treatment of choice for primary prophylaxis of variceal bleeding; sclerotherapy should not be used. β-Blockers can also be considered first-line therapy for the prevention of rebleeding as they compare well with sclerotherapy, are cheap, have few side effects, and protect against bleeding from portal hypertensive gastropathy. Combined therapy with nitrovasodilators may make β-blockers more effective as portal pressure is reduced further and propranolol nonresponders become responders. The reasons for propranolol nonresponse are not clear. The transjugular intrahepatic portosystemic stent shunt is a great innovation that may substitute for surgery in both the acute and elective situation. It may become the treatment of choice for patients who bleed while awaiting a liver transplant, but surgical shunts do not complicate transplantation unduly. Inferior vena caval expandable stents in the Budd-Chiari syndrome may eventually preclude the need of suprahepatic (mesoatrial) shunts.