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Introduction Pre-emptive transjugular intrahepatic portosystemic shunt (TIPS) has been proposed to improve outcomes in patients at high risk for acute variceal bleeding; however, the extent and consistency of its benefits across various patient groups remain uncertain.Methods We searched MEDLINE, Embase, the Cochrane Library, and ClinicalTrials.gov for randomized controlled trials (RCTs) comparing pre-emptive TIPS (placement within 72 hours) to standard therapy in adults with cirrhosis and acute variceal bleeding. The primary outcomes we focused on were all-cause mortality and rebleeding. Secondary outcomes included the incidence of new or worsening ascites, hepatic encephalopathy, spontaneous bacterial peritonitis, hepatorenal syndrome, liver-related mortality, and serious adverse events. We applied random-effects models for the analysis.Results Our analysis included six RCTs involving 431 patients. Pre-emptive TIPS significantly reduced all-cause mortality compared to standard care (Relative Risk [RR] = 0.54; 95% Confidence Interval [CI] = 0.39–0.76) and notably decreased the rate of rebleeding (RR = 0.29; 95% CI = 0.16–0.55). The benefits were consistent across different types of varices and varying degrees of baseline liver disease severity. Additionally, pre-emptive TIPS reduced the risks of new or worsening ascites, hepatorenal syndrome, liver-related death, and serious adverse events without increasing the incidence of hepatic encephalopathy. We did not observe any significant differences in rates of spontaneous bacterial peritonitis.Conclusions In high-risk patients with cirrhosis who are hospitalized for acute variceal bleeding, pre-emptive TIPS leads to substantial reductions in rebleeding and mortality and improves several important clinical outcomes without a corresponding rise in hepatic encephalopathy. These findings support the strategy of early TIPS placement for suitably selected patients.