Balloon guide catheters improve first-pass effect and neurologic outcomes in mechanical thrombectomy: a matched cohort analysis.

BACKGROUND AND PURPOSE: The use of balloon guide catheters (BGCs) versus guide sheaths (GSs) for mechanical thrombectomy (MT) in large-vessel occlusive acute ischemic stroke (LVO-AIS) remains controversial. BGCs provide proximal flow arrest which may improve clot ingestion and reduce distal embolization.

MATERIALS AND

METHODS

A single-center retrospective matched-pair analysis to evaluate procedural efficacy and clinical outcomes as a function of BGC versus GS use for MT was performed. Consecutive patients who underwent MT for anterior circulation LVO-AIS from 2017 to 2025 were included. Subgroup analyses were performed by occlusion site and first-pass technique (ADAPT (aspiration) or CAPTIVE (aspiration and stent retriever)). The primary outcome measure was the first-pass effect (FPE; modified Treatment in Cerebral Infarction (mTICI) 2c-3 after the first pass). Secondary outcome measures included 90-day shift in the modified Rankin Scale (mRS) score, mortality, and time from puncture to recanalization.

RESULTS

A total of 1567 MT cases were included, with 930 matched procedures analyzed (465 BGC, 465 GS). BGC-MT was associated with higher FPE rates (51% vs 44%, P=0.026) and shorter procedural times (median (IQR) puncture to recanalization time 18 (29-13) min vs 23 (35-16) min, P<0.001). BGC-MT demonstrated a significant leftward shift in 90-day mRS distribution (OR 0.78, P=0.009) and lower mortality (28% vs 33%, P=0.04). BGC-MT benefits were most pronounced in CAPTIVE cases and internal carotid artery and middle cerebral artery M1 occlusions.

CONCLUSION

BGC use was associated with superior FPE, shorter procedural times and improved neurologic outcomes, with benefits most pronounced for proximal occlusions. Neurologic benefits of BGC-MT may be driven by technical efficacy improvements, which may depend on operator experience and patient population.