OBJECTIVE: Patients with chronic venous disease can present with different underlying haemodynamic abnormalities affecting the deep, superficial and perforator veins. This review explores the relationship between reflux patterns, extent of venous reflux and clinical manifestations of chronic venous disease. METHODS: The Medline and EMBASE databases were systematically searched from 1946 to 1st April 2024. References of shortlisted papers were searched for relevant articles. Studies were included if they were in English language, included participants ≥16 years of age, documented reflux patterns in ≥2 of the following: deep, superficial and/or perforator systems, and related patterns to presentation or severity. Exclusion criteria included patients with isolated deep venous thrombosis, post-thrombotic syndrome or stenotic or obstructive disease. RESULTS: 18 studies were identified (11,177 participants, range 55 to 3016). Meta-analysis showed significant odds ratios (OR) for C4-6 disease being associated with deep reflux (OR 2.41, 95% confidence interval (CI) 1.53-3.78) and perforator reflux (OR 3.37, 95% CI 2.16-5.27), but not superficial reflux (OR 2.11, 95% CI 0.87-5.14), versus C0-3 disease. Severe chronic venous disease (C4-6) was significantly associated with isolated deep, combined deep/superficial and combined superficial/perforator reflux. The highest risk of CVD progression (defined as de novo development of varicose veins and progression to greater CVD severity) was shown by two studies to be related to combined deep/superficial reflux. CONCLUSIONS: While limited by the heterogenous nature of the studies, this review confirms that reflux pattern is a significant predictor of clinical class, and higher CEAP stages are associated with higher prevalence of superficial, deep and perforator reflux. Isolated deep and combined reflux also appear to predict the onset of leg ulceration. Future studies should relate reflux patterns to treatment outcomes, including recurrence risk. This could help inform health policies and management guidelines so that reflux patterns, in conjunction with other demographic and haemodynamic parameters, could be used to risk stratify patients and identify individuals that may benefit from earlier treatment.