Background and Aims For patients with hepatocellular carcinoma (HCC) and portal vein tumor thrombus (PVTT), the surgical resection rate is low and the recurrence rate is high, resulting in poor prognosis. Its treatment method is still controversial. In this paper, the authors summarize the experience of surgical treatment of resectable HCC combined with PVTT, and compare the short- and long-term efficacy of surgery and transcatheter arterial chemoembolization (TACE) for these patients.Methods The clinical data of 39 patients with resectable HCC and concomitant PVTT treated from March 2016 to March 2021 were retrospectively analyzed. Of the patients, 23 cases underwent surgical treatment (surgery group) and 16 patients were treated with TACE (TACE group). The main clinical variables and prognosis were compared between the two groups of patients, and the influencing factors for the prognosis of patients were analyzed.Results In surgery group, except one patient who had extensive tumor invasion and only underwent tissue sample removal for biopsy, surgery was completed in all the remaining patients, without surgical death; 19 patients had negative surgical margins; 2 patients developed postoperative liver failure, and were cured and discharged after treatment with artificial liver support and supportive measures. In TACE group, the super-selection, perfusion and embolization of the hepatic arteries were uneventfully performed in all the 16 patients; 1 patient died of acute liver failure 3 d after TACE due to the complete embolization of the hepatic artery. In surgery group, 8 underwent adjuvant TACE after operation and 5 patients received targeted therapy, one of whom with type I PVTT still survived for 47 months after postoperative treatment such as TACE. In TACE group, 13 patients underwent repeated treatment and 4 patients received targeted therapy, one of whom with type II PVTT undergoing 7 times of interventional perfusion chemotherapy and embolization still survived for 25 months. In surgery group compared with TACE group, the operative time was prolonged, the medical cost was increased, the number of cases undergoing postoperative TACE was decreased, and the numbers of cases without any other postoperative treatment and cases whose postoperative AFP level returned to normal were increased (all P<0.05). The median survival time was 16.2 months for surgery group and 9.5 months for TACE group, and the 0.5-, 1-, 2- and 3-year survival rates were 65.2%, 43.5%, 34.8% and 17.4% for surgery group, and 46.7%, 33.3.0%, 13.3% and 0 for TACE group, respectively. There were significant differences in median survival time and accumulate survival rate between the two groups (both P<0.05). Results of univariate analysis showed that PVTT classification, AFP level, tumor size, tumor number were related to postoperative survival time of patients (all P<0.05). Results of multivariate analysis revealed that treatment mode, PVTT classification, tumor diameter and AFP level were independent influencing factors for postoperative survival time (all P<0.05).Conclusion PVTT classification, tumor diameter and AFP level can directly affect the survival of patients with HCC and PVTT. The efficacy of surgical resection is significantly better than that of TACE, especially for those with resectable HCC and type I/II PVTT. However, the treatment choice may be limited by the patient's will and economic factors.