Background Accurate assessment of limb perfusion is critical in management of chronic limb threatening ischaemia (CLTI). Conventional non-invasive methods are limited in patients with calcified vessels, extensive tissue loss and previous minor amputation. Pedal acceleration time (PAT) is a duplex ultrasound-based technique that quantifies pedal arterial haemodynamics and has been proposed as a prognostic tool in the management of patients with CLTI. Methods A systematic review was conducted in accordance with PRISMA guidelines. Medline, EMBASE, Emcare, and Cochrane Central were searched for studies evaluating PAT in patients with CLTI. Outcomes included wound healing, amputation-free survival (AFS), and all-cause mortality at 1 year. Data was pooled using random-effects models where appropriate. Results Four studies comprising of 472 patients and 515 limbs were included. All studies assessed PAT post-revascularisation. Pooled analysis demonstrated higher PAT values associated with major limb amputation at one year (mean difference 77.9ms, 95% CI 39 – 116ms, p < 0.001). At one year, PAT < 180ms was associated with wound healing at one year (RR 5.29, 95% CI 1.13 – 24.8, p = 0.03), but not AFS (RR 4.83, 95% CI 0.70 – 33.6, p = 0.11). Risk of bias was moderate to high, due to small sample sizes and single-centre design of studies. Conclusion Post-revascularisation PAT demonstrates an association with wound healing and major amputation in patients with CLTI. Evidence certainty is low and limited by small and heterogeneous cohorts. Larger prospective studies are required to validate PAT as a prognostic tool and assess its utility alongside established perfusion measures.