To assess factors including portosystemic surgical shunts in survival of patients with Budd-Chiari syndrome, a multivariate retrospective analysis on 120 patients (surgical shunts 82 and 38 medically managed) hospitalized between 1970 and 1992 was performed. The 1, 5 and 10 year survival rates were 77±4%, 64±5% and 57±6% respectively. Survival was significantly better in the patients diagnosed after 1985 compared to the prior period. Four factors were found to be inversely and independently related to survival: age, response of ascites to diuretics, Pugh score and serum creatinine. In patients diagnosed since 1985, an index combining these four factors allowed differentiation of patients with good outcome (5 year survival, 95%) and those with poor outcome (62%, p<0.05). Surgical shunts had no influence on outcome. In conclusion, age, severity of liver failure, presence of refractory ascites are the main prognostic factors in this condition. It is believed that increased survival in recent years is consistent with improved general care and management of the hypercoagulable state. Since surgical shunts were not found to significantly influence outcome, placement of these shunts should be restricted to patients with refractory ascites or variceal bleeding and with otherwise good prognostic factors.