Endoscopic ultrasound-guided biliary drainage (EUS-BD) has emerged as an important alternative to transpapillary biliary drainage by endoscopic retrograde cholangiopancreatography (ERCP) for malignant biliary obstruction (MBO), especially in cases with failed ERCP. Given the increasing evidences of safety and effectiveness of EUS-BD, EUS-BD as primary biliary drainage has been investigated in clinical trials. However, there are still obstacles that need to be addressed prior to clinical application. In this narrative review, clinical outcomes, hurdles and future perspectives of primary EUS-BD for MBO are discussed.