Abstract:Background and Aims The management of chronic venous disease has gradually shifted from extensive anatomical removal toward hemodynamic-oriented precision treatment. Whether all varicose tributaries should be routinely removed during endovenous radiofrequency ablation (RFA) remains controversial. This study aimed to evaluate the efficacy and safety of hemodynamically guided selective tributary phlebectomy combined with RFA for primary lower extremity varicose veins.Methods A retrospective analysis was conducted on 166 patients with primary lower extremity varicose veins who underwent RFA at Beijing Tongren Hospital, Capital Medical University, between December 2024 and November 2025. According to the tributary treatment strategy, 56 patients underwent RFA with conventional extensive stab phlebectomy (conventional group), whereas 110 patients underwent RFA with hemodynamically guided selective tributary phlebectomy (modified group). Baseline characteristics, perioperative outcomes, postoperative complications, duplex ultrasound findings, the Venous Clinical Severity Score (VCSS), and the Chronic Venous Insufficiency Questionnaire-20 (CIVIQ-20) scores were compared.Results No significant differences were observed between the two groups regarding age, sex, disease duration, preoperative VCSS, or CIVIQ-20 scores (all P>0.05). However, the modified group had a higher proportion of CEAP class C3 patients, whereas CEAP class C2 patients predominated in the conventional group (both P<0.05). Compared with the conventional group, the modified group showed a significantly higher use of local anesthesia, shorter operative time, fewer skin incisions, less intraoperative blood loss, and lower pain scores at 1 h after surgery (all P<0.05). No significant differences were found in ablation time or pain scores before discharge (both P>0.05). At 1 and 3 months after surgery, the incidences of residual varicose veins and subcutaneous induration, as well as duplex ultrasound findings, were comparable between the two groups (all P>0.05). Both groups achieved significant improvements in VCSS and CIVIQ-20 scores compared with baseline (all P<0.05). Although VCSS improvement was less pronounced in the modified group (P<0.05), the improvement in CIVIQ-20 scores was similar between groups (P>0.05).Conclusion Hemodynamically guided selective tributary phlebectomy combined with RFA is a safe and effective treatment for primary lower extremity varicose veins. It achieves comparable short-term clinical outcomes to conventional extensive phlebectomy while reducing surgical trauma, operative time, and blood loss, thereby facilitating perioperative recovery.