Background and Aims High ligation and stripping (HLS) of the great saphenous vein is a classic procedure for the treatment of varicose veins of the lower limbs. However, it has drawbacks such as significant trauma, longer recovery time, and unsightly incision scars. With the advancement of medical technology, minimally invasive treatment techniques, represented by endovenous thermal ablation, have flourished. This study aims to compare the clinical efficacy of radiofrequency ablation (RFA) with traditional HLS for the treatment of lower extremity varicose veins.Methods The clinical and follow-up data of 272 patients (298 limbs) who underwent surgical treatment for primary lower extremity varicose veins at Beijing Anzhen Hospital, Capital Medical University, from May 2021 to June 2022 were retrospectively analyzed. Of the patients, 96 cases (100 limbs) underwent RFA treatment (RFA group), and 176 cases (198 limbs) underwent HLS treatment (HSL group). The preoperative clinical characteristics, surgical details, complications, changes in clinical-etiological-anatomical-pathophysiological (CEAP) classification, venous clinical severity score (VCSS), and Chronic Venous Insufficiency Questionnaire-14 items (CIVIQ-14) scores were compared between the two groups.Results The technical success rate was 100% in both groups, and ultrasound examinations on postoperative day 3 showed a 100% absence/closure rate of the main trunk of the great saphenous vein. A total of 265 patients (290 limbs) completed the follow-up, with a mean follow-up time of (13.2±3.8) months. During the follow-up period, the absence/closure rate of the main trunk of the great saphenous vein was 100% as indicated by ultrasound in both groups. There were no significant differences in the basic clinical characteristics between the two groups (all P>0.05). Compared to the HSL group, the RFA group had significantly lower intraoperative blood loss (21.3 mL vs. 46.8 mL), postoperative day 1 pain scores (3.1 vs. 3.3), overall incidence of complications (25.5% vs. 38.0%), and incidence of abnormal skin sensations (5.1% vs. 24.0%) (all P<0.05). The RFA group had a higher incidence of deep vein thrombosis (5.1% vs. 0, P<0.05). After the procedure, all patients in both groups showed a downgrade in CEAP classification compared to that before the procedure. In the RFA group, 81.7% of limbs were downgraded to C0-C1 level, while in the HSL group, 83.9% of limbs were downgraded to C0-C1 level. VCSS and CIVIQ-14 scores of all patients improved compared to those before the procedure, and the improvement in VCSS score was greater in the HSL group than that in the RFA group (all P<0.05).Conclusions RFA has comparable short-term efficacy to HSL and offers advantages of smaller trauma, less pain, and lower complication rate compared to HSL. It is an effective treatment option for lower extremity varicose veins.