Background: Anlotinib, a novel small molecule multi-target tyrosine kinase inhibitor that can effectively inhibit VEGFR, PDGFR, FGFR, C-KIT et al, is proved to have anti-tumor angiogenesis and tumor growth inhibition effects. However, Anlotinib exploration on advanced pancreatic adenocarcinoma (PDAC) is still limited. The motivation of this work is to evaluate the efficacy and safety of anlotinib combined with nab-paclitaxel/gemcitabine in the first-line treatment of patients with advanced PDAC, and provide some evidence for the treatment regimens of advanced PDAC. Methods: This was a retrospective study in patients with advanced PDAC performed from Aug 17, 2019 to Apr 3, 2021. Patients who received anlotinib plus nab-paclitaxel/gemcitabine treatment were defined as Group 1, and patients who received nab-paclitaxel/gemcitabine as Group 2. The study was approved by the Ethics Committee of the First Affiliated Hospital of Anhui Medical University (P2021-13-21). The response to treatment was evaluated according to RECIST version 1.1. In addition, adverse events were evaluated by CTCAE v5.0. Results: In this work, 33 patients were included, with 17 cases in Group 1 and 16 cases in Group 2. The median PFS (mPFS) of Group 1 and Group 2 were 5.0 (95% Cl, 4.97-5.94) months and 2.7 (95% Cl, 2.4-3.3) months, respectively (P = 0.0220). The median OS (mOS) of Group 1 and Group 2 were 9.0 (95% Cl, 6.55-11.45) months and 6.0 (95% Cl, 1.08-10.92) months, respectively (P=0.006). The PFS rate in 3 and 6 months and the OS rate in 6 and 12 months of Group 1 were significantly higher than that of Group 2. The most common grade 3 treatment related AEs (trAEs) were hematological toxicity, with 35.29% in Group1 and 31.25% in Group 2. Non-hematological toxicity were hypertension, hand-foot syndrome and diarrhea. No grade 3 or higher non-hematologic toxicity was observed in all patients. Conclusions: Anlotinib plus nab-paclitaxel/gemcitabine as first-line treatment demonstrates encouraging efficacy and manageable AE in patients with advanced PDAC. Clinical outcomes are improved with longer PFS and OS in anlotinib plus chemotherapy group. More data are needed to confirm the long-term efficacy and safety of anlotinib plus nab-paclitaxel/gemcitabine in advanced PDAC patients.