Background and Aims Liver resection (LR) and transcatheter arterial chemoembolization (TACE) are widely used in the treatment of rupture and bleeding of primary liver cancer (PLC). However, there are still great differences in the efficacy results from relevant reports. So far, the consensus on the most appropriate treatment strategy to reduce in-hospital mortality and improve long-term survival has not been established. Therefore, this study was conducted to compare the clinical efficacy and prognosis of LR and TACE in the treatment of PLC rupture and bleeding through a retrospective analysis, so as to provide the optimal treatment strategy for this condition.Methods Using a retrospective case-control design, 195 patients with ruptured PLC treated in three medical centers from June 2013 to June 2018 were enrolled, and divided into LR group (64 cases) and TACE group (131 cases) according to the treatment methods. After balancing the baseline characteristics by propensity score matching (PSM), the 1-, 2- and 3-year overall survival (OS) rates between the two groups were compared, and the risk factors affecting the OS of patients were analyzed.Results A total of 29 pairs of patients in the two groups were successfully matched after PSM with a 1∶1 ratio. There was no statistical difference in 30-d mortality between LR group and TACE group (3.4% vs. 10.3%, P=0.611). The 1-, 2- and 3-year OS rates were 75.9%, 41.4% and 12.9% for LR group, and were 55.5%, 14.4%, and 0 for TACE groups, respectively; the median OS was 18.5 (95% CI=12.9-24.1) months for LR group and 12.5 (95% CI=10.4-14.6) months for TACE group, and the difference had statistical significance (χ²=4.843, P=0.028). Univariate analysis showed that portal vein invasion, portal hypertension, ascites, multiple lesions, tumor diameter >10 cm, Child-Pugh grade, BCLC stage, AFP >400 ng/mL and treatment method were risk factors affecting the OS of patients with ruptured hemorrhagic PLC (all P<0.05); multivariate Cox analysis revealed that multiple lesions, Child-Pugh grade, AFP >400 ng/mL and treatment method were independent risk factors for the OS of patients with ruptured hemorrhagic PLC (all P<0.005).Conclusion Treatment method is an independent prognostic factor for patients with ruptured hemorrhagic PLC, the comprehensive treatment containing LR can offer more survival benefits than TACE to patients with this condition.