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Objectives To evaluate survival and clinical outcomes in patients with amyotrophic lateral sclerosis (ALS) undergoing radiologically inserted gastrostomy (RIG) and to describe outcomes in patients in whom gastrostomy was indicated but not performed.Methods This retrospective observational cohort study included patients with ALS followed by a multidisciplinary palliative care team between 2018 and 2020. Patients were classified according to gastrostomy status (RIG vs no RIG). Clinical data, respiratory support, nutritional status and survival outcomes were collected from medical records. Survival was analysed from gastrostomy indication using Kaplan-Meier curves stratified by baseline non-invasive ventilation (NIV) use.Results Among 155 patients with ALS, RIG was indicated in 53 and performed in 45; eight patients died before the procedure. 65 patients did not undergo gastrostomy. Median survival after RIG was 14.7 months, compared with 8 months in non-RIG patients who died. Baseline NIV use was associated with longer survival. No major safety concerns were identified.Conclusions RIG appears to be a safe and feasible option in advanced ALS. Multidisciplinary care with integrated palliative involvement may facilitate referral, optimise nutritional support and support shared decision-making aligned with patients’ goals of care. Further prospective studies are needed to confirm benefits and identify intervention timing.