Objective <p>This retrospective cohort study aims to compare the efficacy and safety of endovascular intervention with conservative therapy in patients with Budd-Chiari syndrome (BCS).</p> Methods and materials <p>A total of 188 patients diagnosed with BCS were divided into endovasular intervention (n = 108) and conservative therapy (n = 80) groups. Primary endpoints were clinical success and overall survival (OS) at 24 months. Clinical success was defined as a ≥ 50% reduction in ascites and the absence of variceal bleeding within 6 months. Secondary outcomes included improvement in liver function and incidence of major complications.</p> Results <p>The clinical success rate was significantly higher in the endovasular intervention group compared to the conservative therapy group [77.0% <i>vs</i>. 41.3%; <i>p</i>&lt; 0.001; relative risk (<i>RR</i>) = 1.86; 95% confidence interval (<i>CI</i>): 1.41-2.45]. The 24-month OS was superior in the endovasular intervention group [95.4%<i>vs</i>. 85.0%; hazard ratio (<i>HR</i>) = 0.30, 95% <i>CI</i>: 0.09-0.80; <i>p</i>= 0.02]. Patients receiving endovascular intervention demonstrated greater improvement in liver function. No significant difference was found in the incidence of major complications between the two groups (1.6% <i>vs</i>. 2.5%; <i>p</i>= 0.64).</p> Conclusion <p>Endovascular intervention is associated with significantly higher clinical success rate and a 70% reduction in 2-year mortality compared to conservative therapy, without an increase in major complications. These results support the use of endovascular intervention as a preferred first-line treatment in appropriately selected patients with BCS.</p> Practice Implications <p>The clinical advantages of endovascular intervention underscore the need for standardized treatment protocols in BCS. Early implementation of interventional strategies by hepatologists and radiologists may enhance both OS and quality of life for patients.</p>