Purpose <p>This study aimed to evaluate the technique of performing percutaneous radiologic gastrostomy (PRG) by directly puncturing the stomach under ultrasound (US) guidance in patients in whom nasogastric (NG) tube placement was not feasible.</p> Methods <p>Between July 2013 and July 2024, 39 US-guided PRG procedures were attempted in 37 consecutive patients without NG tubes. The initial gastric puncture was performed under US guidance using a 21-22-gauge Chiba needle. The needle was then exchanged for a 6&#xa0;F Neff catheter, which was used to distend the stomach. Subsequently, a gastrostomy tube was inserted using the conventional technique. Patient demographics, technical success, clinical success, and complications were retrospectively evaluated using electronic medical records. Complications occurring within 30 days of the procedure were categorized according to the Society of Interventional Radiology classification.</p> Results <p>Of 39 procedures, 37 (94.9%) were technically successful. In two cases in which the initial US-guided PRG failed, an angiographic catheter was inserted transorally into the stomach to achieve distension, followed by conventional PRG. All 39 procedures (100%) achieved clinical success, and the patients successfully received nutrition via the gastrostomy tube. No immediate complications occurred. One major late complication (intraperitoneal abscess) and three minor late complications (skin infection, <i>n</i> = 2; tube leakage, <i>n</i> = 1) occurred within 30 days of the procedure. These complications were not associated with the US-guided access itself.</p> Conclusion <p>Performing PRG via direct gastric puncture under US guidance is a safe and effective alternative for patients without an NG tube.</p>