Background and Aims Currently, surgery remains the primary treatment for colorectal cancer, while neoadjuvant therapy can transform initially unresectable lesions into resectable ones, improving patient prognosis. Bevacizumab combined with chemotherapy has shown promising efficacy for advanced metastatic colorectal cancer; however, the routine use of bevacizumab in neoadjuvant therapy for potentially resectable metastatic colorectal cancer patients remains controversial. Therefore, this study was performed to investigate the efficacy and safety of bevacizumab combined neoadjuvant therapy in patients with locally advanced rectal cancer (LARC).Methods The clinical data of LARC patients who received bevacizumab-combined neoadjuvant therapy in the Department of Colorectal and Gastrointestinal Oncology, Jilin Cancer Hospital, from 2021 to 2022, were retrospectively analyzed.Results A total of 45 patients were included, of whom 26 received the XELOX (oxaliplatin combined with capecitabine) + bevacizumab neoadjuvant regimen (chemotherapy plus bevacizumab group), and 19 received radiotherapy concurrent with XELOX and sequential bevacizumab neoadjuvant treatment (chemoradiotherapy plus bevacizumab group). Preoperative imaging evaluations showed tumor response rates of 84.61% and 94.74%, respectively, with a disease control rate of 100.0% in both groups. The CEA and CA19-9 levels significantly decreased compared to their pre-treatment levels in both groups (both P<0.05). In the chemotherapy plus bevacizumab group, all patients underwent Dixion resection with D₂ lymphadenectomy, with 10 patients receiving preventive ileostomy. Postoperative pathology showed an average of 18.3 lymph nodes removed, with 2.1 metastatic nodes; tumor regression grade (TRG) was 0 in 2 cases (7.69%), 1 in 8 cases (30.77%), 2 in 10 cases (38.46%), and 3 in 6 cases (23.08%). In the chemoradiotherapy plus bevacizumab group, 15 patients underwent Dixion resection with D₂ lymphadenectomy, 2 patients underwent Miles surgery, 1 patient was unable to undergo surgery due to severe pelvic adhesions, and another was unable to have resection due to pelvic floor adhesions found during surgery. Preventive ileostomy was performed in all 15 patients who had Dixion surgery. Postoperative pathology showed an average of 18.5 lymph nodes removed, with 1.6 metastatic nodes; TRG was 0 in 2 cases (10.53%), 1 in 7 cases (36.84%), 2 in 6 cases (31.58%), and 3 in 2 cases (10.53%). Surgical specimens in both groups showed negative proximal and distal margins, with no tumor residuals. A total of 55 neoadjuvant therapy-related adverse events occurred, all graded 1-2, without affecting subsequent treatment.Conclusion For LARC patients, bevacizumab-combined neoadjuvant therapy is safe and effective. Bevacizumab combined with chemotherapy can be selected, with radiotherapy as an option based on tumor location, to increase the probability of radical resection and sphincter-preserving opportunities.