In this large single-center retrospective study of 348 patients with refractory ascites due to alcoholic cirrhosis, peritoneovenous shunt (PVS) implantation demonstrated meaningful long-term survival (1-year 63%, 5-year 23%) and clinical utility, particularly in patients not eligible for TIPS or liver transplantation. Outcomes were primarily driven by underlying liver disease severity (MELD/Child-Pugh), while shunt occlusion—often cited as a limitation—did not negatively impact survival when managed with reintervention. Overall, the findings challenge the current limited role of PVS in guidelines and support its use in carefully selected patients.