Intrahepatic cholangiocarcinoma (ICC) is a highly aggressive liver malignancy characterized by a subtle onset and rapid progression. Most patients are diagnosed at advanced stages, making radical surgical resection impossible, and the overall prognosis is poor. The ability to convert initially unresectable ICC to resectable tumors through multimodal comprehensive treatment is significant for prolonging patient survival. In recent years, with the application of immunotherapy and targeted therapy in advanced ICC, as well as improvements in surgical techniques, radiation therapy, hepatic arterial infusion chemotherapy, and selective internal radiation therapy, along with updates in treatment strategies and concepts, some initially unresectable ICC tumors have become resectable following downstaging with various treatment modalities, which has brought new hope for improving conversion resection success rates and patient prognosis. However, conversion therapy for ICC still faces numerous challenges and controversies, including the lack of a recognized standard treatment regimen, limited overall conversion success rates, a lack of long-term follow-up data to demonstrate survival benefits after conversion resection, and unresolved issues such as whether patients who achieve clinical complete remission should undergo resection or be monitored. Given that most current studies on ICC conversion therapy are small-sample, retrospective studies or case reports, lacking high-level evidence from randomized controlled trials, and the majority of studies include various types of biliary tract cancers without considering the heterogeneity across different anatomical locations, the relevance of these findings for guiding ICC conversion treatment strategies is limited. There is an urgent need for high-quality, multi-center, large-sample, prospective clinical studies and basic research to explore optimal ICC translational therapy regimens with rapid efficacy, high objective response rates, and good safety profiles, identify patient populations with potential benefits from different treatments, and develop individualized treatment strategies to improve conversion success rates and ultimately enhance patient prognosis. This article reviews the progress in the conversion treatment of unresectable ICC, intending to provide a reference for clinical practice.