Managing esophageal varices, particularly those unresponsive to standard therapies, poses significant challenges for patients with portal hypertension. This comprehensive review explores updated treatment options, contrasting international guidelines, and proposes alternative therapies after primary treatments like endoscopic variceal ligation (EVL) fail. While EVL is effective in the majority of cases, options such as endoscopic injection sclerotherapy and transjugular intrahepatic portosystemic shunt are vital in persistent cases. Japanese practices differ, focusing more on partial splenic embolization, reflecting regional healthcare disparities. Continuous advancements in treatment strategies aim to enhance patient outcomes.