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Safe and accurate femoral venous access is fundamental to the success of radiofrequency catheter ablation (RFCA) for atrial fibrillation (AF), particularly under uninterrupted anticoagulation, where vascular injury may lead to amplified bleeding and thrombotic risk. Conventional landmark-based puncture is limited by anatomical variability, whereas ultrasound guidance has shown potential to enhance puncture safety. This multicenter retrospective cohort study included 300 AF patients undergoing RFCA across 3 tertiary hospitals from September 2024 to December 2025 under uninterrupted anticoagulation. Patients were assigned to a preprocedural ultrasound localization group (n = 150) or a conventional anatomical landmark group (n = 150). Baseline characteristics were compared, and puncture efficiency, intraoperative events, puncture-related complications, operative metrics, postoperative recovery, and additional intervention requirements were evaluated. Multivariable logistic regression was used to adjust for confounders. Preprocedural ultrasound markedly improved puncture performance, achieving a higher first-attempt success rate (87.3% vs 59.3%, P <.001), fewer attempts (1.3 ± 0.6 vs 2.4 ± 1.1, P <.001), and shorter puncture time (4.6 ± 1.2 vs 6.8 ± 1.5 minutes, P <.001). Ultrasound-detected anatomical variations in 44% of patients, including venous deviation, duplication, stenosis, and venous-arterial overlap. Safety outcomes favored the ultrasound group, showing reduced arterial mispuncture (2.7% vs 14.0%), blood vessel spasm (3.3% vs 11.3%), and abnormal catheter path events (2.0% vs 11.3%) (all P <.01). Puncture-related complications were significantly decreased, including overall hematoma (10.0% vs 31.3%), persistent oozing (6.7% vs 17.3%), infection (0.7% vs 4.7%), deep vein thrombosis (2.0% vs 7.3%), pseudoaneurysm (0% vs 4.0%), and arteriovenous fistula (0.7% vs 4.7%) (all P <.05). Ultrasound localization also reduced operative difficulty scores (1.9 ± 0.8 vs 3.2 ± 1.1, P <.001) and shortened total procedural duration (118.7 ± 25.4 vs 133.3 ± 30.4 minutes, P <.001). Postoperative pain at 2 and 24 hours was significantly lower, and bed rest time was shorter, though length of stay was similar between groups. Additional interventions - extended compression, hematoma drainage, and anticoagulation adjustment - were markedly less frequent in the ultrasound group (overall 4.7% vs 21.3%, P <.001). Preprocedural femoral venous ultrasound localization significantly enhances puncture accuracy, reduces vascular complications, improves procedural efficiency, and accelerates postoperative recovery in AF patients undergoing RFCA under uninterrupted anticoagulation. These findings support incorporating ultrasound-based localization into routine preprocedural assessment to optimize the safety and quality of electrophysiological interventions.