Endoscopic ultrasound (EUS)-assisted biliary access is utilized when conventional endoscopic retrograde cholangiopancreatography (ERCP) fails. We report a 10-year experience utilizing a transduodenal EUS rendezvous via a transpapillary route without dilation of the transduodenal tract, followed by immediate ERCP access. Patients included all EUS-guided rendezvous procedures for biliary access that were performed following ERCP failure. EUS-assisted bile duct puncture was performed via a transduodenal approach and a guide wire was advanced through the papilla without any dilation or bougienage of the tract; ERCP was performed immediately afterwards. EUS-assisted biliary rendezvous was attempted in 15 patients (mean age 66±18.2 years; malignant=10, benign=5). Mean diameter of measured bile ducts was 14.3±5.17mm (range 423mm). The reasons for initial ERCP failure were tumor infiltration or edema (n=9), intradiverticular papilla (n=2), pre-existing duodenal stent (n=1), and anatomic anomalies (n=3). Successful EUS-guided bile duct puncture and wire passage were achieved in all 15 patients (100%), with drainage being successful in 12/15 (80%). Failures occurred in three patients due to inability to traverse the biliary stricture (n=2) or dissection of a choledochocele with the guide wire (n=1); all were subsequently drained via percutaneous methods. Stents placed were metallic in eight patients and plastic in four. Complications consisted of moderate pancreatitis after a difficult ERCP attempt in one patient, and bacteremia after percutaneous biliary drainage in another. There were no instances of perforation, extraluminal air or fluid collections. EUS-assisted biliary drainage utilizing a transduodenal rendezvous approach demonstated a high success rate without any complications directly attributable to the EUS access. Advantages over percutaneous biliary and other methods of EUS biliary access include performance under the same anesthesia, and a very small-caliber needle puncture similar to EUS/fine-needle aspiration.