Background <p>Parastomal varices are a rare but serious complication in patients with portal hypertension, characterised by bleeding that can be life-threatening in a predominantly comorbid population. Traditional surgical approaches to managing parastomal varices are associated with high morbidity and recurrence rates, prompting increased interest in minimally invasive techniques. This systematic review aims to evaluate the efficacy and safety of interventional radiology (IR) procedures, including transjugular intrahepatic portosystemic shunt (TIPS), sclerotherapy and embolisation, in managing parastomal varices.</p> Methods <p>A comprehensive literature search was conducted across multiple databases, including MEDLINE, EMBASE and Web of Science, to identify studies published up to January 2025 that reported IR interventions for parastomal varices. Data were extracted on patient demographics, procedural success, recurrence rates and complications. A pooled proportions meta-analysis was performed.</p> Results <p>Five studies, encompassing 45 patients, met the inclusion criteria. The pooled technical success rate of IR procedures was 91.3%, with a clinical success rate of 80.5% over a mean follow-up of 618.4&#xa0;days. The pooled mean proportion of rebleeding, predominantly minor and non-life-threatening, was 36.4%. TIPS showed the highest efficacy, but is traditionally associated with increased procedural risks compared to other interventional radiology methods.</p> Conclusion <p>IR offers a highly effective and safe alternative to traditional surgical management for parastomal varices in contemporary terms. The low recurrence and complication rates highlight the potential of IR ab initio as a first-line treatment; consequently, we advocate for its use, particularly in patients unsuitable for surgery in the minimally invasive era.</p> Systematic review registration <p>PROSPERO CRD42024627470.</p>