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Introduction Porto-sinusoidal vascular disease (PSVD) causes non-cirrhotic portal hypertension (PH) leading to gastroesophageal varices. Due to limited disease-specific evidence, management is largely extrapolated from cirrhosis (Baveno VII). Comparative data on non-selective beta-blockers (NSBB) alone versus NSBB combined with endoscopic band ligation (EBL) in PSVD remain scarce, and real-world practice may vary.The objective of this study was to evaluate real-world variceal bleeding prevention in PSVD by comparing NSBB alone versus combined therapy (NSBB+EBL), and determining whether clinical decisions are driven by prothrombotic etiology or PH phenotype.Methods This retrospective single-center study included PSVD patients followed between January 2018 and December 2025 (minimum 2-year follow-up). Clinical, endoscopic, and therapeutic data were analyzed, focusing on variceal bleeding prevention. Univariate and multivariate analyses identified predictors of bleeding risk and factors guiding therapy.Results A total of 42 patients were included (mean age 38.8±14.4 years, 73.8% female). PH was nearly universal: esophageal varices (EV) in 90.5%, gastric varices (GV) in 31.0%, and portal hypertensive gastropathy (PHG) in 35.7%. The etiological profile was dominated by prothrombotic conditions: protein C deficiency (38.1%), combined protein C/S deficiency (33.3%), and isolated protein S deficiency (11.9%). Splanchnic thrombosis was documented in 61.9%. Long-term anticoagulation (predominantly DOACs) was administered in 76.2%. Underlying disease was controlled in 54.8%.NSBB could not be initiated in 10 patients (23.8%) due to contraindications or intolerance. EBL was performed in 28 patients (66.7%). Patients receiving combined NSBB+EBL therapy had a more severe PH phenotype: 100% EV prevalence vs 69.2% in the NSBB-only group (p=0.007), and higher hemorrhagic decompensation rates (60.7% vs 14.3%, p=0.007).Univariate analysis identified GV (p=0.008) and PHG (p=0.047) as significant predictors of hemorrhagic decompensation. Borderline associations were noted for absence of anticoagulation (p=0.055) and lack of disease control (p=0.061), whereas the etiological profile (protein C/S deficiency) did not influence bleeding risk (p=1.000). Multivariate analysis confirmed that anticoagulation status, disease control, and protein deficiency type were not independent determinants of EBL requirement.Conclusion In PSVD, management strategies for variceal bleeding prevention are guided by PH severity and endoscopic phenotype rather than underlying prothrombotic etiology. GV and PHG emerged as key predictors of hemorrhagic decompensation. These findings support individualized therapy based on endoscopic assessment of bleeding risk rather than the etiological profile.