Acute variceal bleeding is a major cause for mortality in patients with liver cirrhosis with mortality rate around 15%. Resuscitaion with blood tranfusions and volume replacement is a key step in the management of these patients, combined with administration of vasoactive drugs and endoscopic variceal band ligation. Tansjugular intrahepatic portosystemic shunt (TIPS) with appropriate indications is an option for some patients with treatment failure, but also has limitations related to the prognosis of the individual patient. Bridge therapy with balloon tamponade or specially designed coated esophageal stents can be used for unstable patients awaiting definitive treatment. Early TIPS should be the first choice in patients at high risk of treatment failure (Child-Pugh B with active bleeding or Child-Pugh C < 14).