OBJECTIVES: Large volume paracentesis (LVP) is the standard treatment for patients with refractory ascites and portal hypertension. Clinical studies have shown that Transjugular Intrahepatic Portosystemic Shunt (TIPS) represents a valid alternative to reduce the recurrence of the ascites and subsequent LVP sessions, improving mortality but associated with hepatic encephalopathy. A cost-effectiveness analysis was developed studying the use of TIPS with ePTFE covered stent-grafts (SG) compared to LVP in patients with refractory ascites. METHODS:  A 2 years Markov model was adapted to Spanish National Healthcare System perspective in order to measure clinical and economic consequences of TIPS with ePTFE stent-grafts compared to LVP in patients with refractory ascites. Clinical management patterns and resource use were defined by an interview process with Spanish key opinion leaders. The model was populated with clinical data from published literature. Healthcare costs were obtained from Spanish databases and expressed in €2015. Univariate sensitivity analyses were performed to test the robustness of the model. RESULTS: The economic model shows that TIPS with ePTFE covered stent-grafts was a dominant (cost saving and reduced mortality) option compared to LVP in patients with refractory ascites. Total treatment costs per patient were €14,728 for TIPS and €15,360 for LVP, with €632 cost saving per patient. Main costs savings obtained with TIPS implants came from the avoided LVP sessions. Over 2 years, mortality was reduced in TIPS arm by 20% compared to LVP treatment, resulting in 0.17 life-years gained (LYG) per patient. Sensitivity analysis corroborated the robustness of the model indicating that the results could have been underestimated as main clinical data derive from a meta-analysis of TIPS with uncovered stents. CONCLUSIONS: TIPS with ePTFE covered stent-grafts compared to LVP represent a more efficient (cost saving and reduced mortality) therapeutic option in the management of patients with recurrent ascites.