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.