Abstract Background and aims Mechanical thrombectomy (MT) is effective for acute Basilar artery occlusion(BAO), but the optimal technique for quick recanalization and improved outcomes remains unclear. We compared Stent retriever (SR), Contact aspiration (CA) and combined SR plus CA technique as first-line approach during mechanical thrombectomy for BAO. Methods We emulated a hypothetical trial comparing CA, SR and combined technique as first-line in patients with BAO, using data from the Italian Registry of Endovascular Treatment. The primary outcome was first-pass effect (FPE), defined as mTICI 2b-3 with 1 pass of MT. We used inverse probability weighting (IPW) adjusted for prespecified covariates to weight each individual’s contribution to the outcome. Results We included 960 patients with BAO treated with MT: 570 with CA, 268 with SR, and 122 with combined technique as first approach. After applying IPW, SR was associated with lower odds of FPE as compared to CA (aOR 0.4895%CI 0.33-0.70), no differences were found comparing SR versus combined technique neither CA versus combined technique. First-pass mTICI 3 was less frequent with SR as compared to CA (0.6295%CI 0.43-0.90). 90-day mRS 0-3 after FPE was more frequent with CA as compared to both SR (aOR 0.5795%CI 0.38-0.85) and combined technique (aOR 0.5095%CI 0.28-0.89). The results were consistent across all the subgroups (p for interaction0.05). Conclusions In patients with BAO, CA was more effective than SR and was associated with better oucome compared to other techniques. Therefore, less traumatic approaches might be preferred as first-line in BAO. Conflict of interest E.N. is member of the medical and scientific advisory board of Cercare Medical and declares speaker's honoraria from Boehringer Ingelheim; A.C. has nothing to disclose; V.S. has nothing to disclose; G.P. has nothing to disclose; P.N. has nothing to disclose; M.D. has nothing to disclose; M.R. has nothing to disclose; D.T. declares consulting or advisory board fees or speaker’s honoraria from Alexion, ASTRA Zeneca, Boehringer, Medtronic and Pfizer. Figure 1 - belongs to Methods Figure 2 - belongs to Results
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