Objective: To investigate the efficacy of ultrasound-guided percutaneous double-tract cholecystostomy and choledochoscopic gallbladder-preserving cholecystolithotomy for high-risk elderly patients with acute calculous cholecystitis. Methods: The clinical data of 30 patients with acute calculous cholecystitis, who underwent percutaneous cholecystostomy and choledochoscopic cholecystolithotomy from January 2012 to April 2013, were retrospectively analyzed. Results: Gallbladder punctures and tube placement were successfully performed in all the 30 patients. Bleeding occurred in one patient during the procedure, which was controlled by intraluminal injection of reptilase and catheter occlusion. The tube retention time was 14 d to 2 months with average of 30 d. After 4- to 8-week drainage, gallbladder stones in 28 patients were successfully removed via choledochoscope, one patient underwent open cholecystectomy because of failure of sinus tract formation, and another patient received laparoscopic cholecystectomy due to loose connection of the 16-F cholecystostomy pigtail tube. Twenty-eight patients were followed up for 3 to 19 months, and recurrence was found in one patient (3.6%) by B ultrasonic examination. Conclusion: Ultrasound-guided percutaneous double-tract cholecystostomy and choledochoscopic gallbladder-preserving cholecystolithotomy is a reliable and effective approach for high-risk elderly gallstone patients.