Balancing flow arrest and aspiration: The relationship between balloon guide catheters, large-bore aspiration, and first pass effect in mechanical thrombectomy

Background Balloon guide catheters (BGCs) have been associated with higher rates of first pass effect (FPE) in endovascular thrombectomy. Large-bore aspiration catheters (ACs) placed at the face of the embolus may mimic the flow arrest effect seen with BGCs; combined use and its effect on FPE have not been previously well-studied. This study aims to evaluate the impact of this dual-device strategy on achieving FPE. Methods We conducted a retrospective cohort study across three sites (2018–2024). A multicenter registry was queried for adult patients with anterior circulation acute ischemic stroke treated with thrombectomy. The primary outcome was rate of FPE (modified Treatment in Cerebral Infarction (mTICI) 2C/3 on the first pass). Multivariable logistic regressions for likelihood of FPE were performed. Results 973 patients were included, with a median age of 69 years (IQR 59–79). BGCs were used in 26.3%. Large-bore ACs were used in 68.7%. In most cases, large-bore ACs were used without a BGC (BGC-: 77.5% vs. BGC+: 43.8%, P < .001). FPE was achieved in 3—0.6% of procedures. BGC usage was significantly associated with FPE (aOR: 1.94, 95% CI: 1.01–3.72, P = .04). When sub-stratified by BGC use, large-bore AC use was found to be significantly associated with FPE only when a BGC was not used (aOR: 3.34, 95% CI: 1.01–12.14, P = .04). Conclusion BGC use is associated with an increased likelihood of FPE; when BGCs were not used, large-bore ACs were significantly associated with a higher likelihood of FPE. These findings are important when considering which tools contribute to successfully achieving FPE.