Balloon Guide Catheter Use and Outcomes After Endovascular Thrombectomy for Ischemic Stroke Due to Large Vessel Occlusions

Background Balloon-guide catheters (BGC) have been associated with improved procedural and functional outcomes following endovascular thrombectomy (EVT) in multiple observational studies. Recently the PROTECT-MT trial challenged this benefit, showing worse functional outcomes when using BGCs. This study aims to assess the association between BGC-use and procedural and functional outcomes in a large real-world cohort. Methods Patients who underwent EVT for anterior circulation large vessel occlusion (LVO) between 2017 and 2021 were included in two Swedish registries: EVAS and Riksstroke. Outcomes included recanalization success (modified Treatment In Cerebral Infarction [mTICI] 2b/2c–3), good 90-day functional outcome (modified Rankin Scale score 0–2), and safety outcomes (iatrogenic dissection, perioperative embolization, early neurological deterioration, and 90-day mortality). Subgroup analysis was conducted by first-line EVT strategy: stent-retriever (with/without aspiration) or contact aspiration alone. Results Of 4843 patients, 2483 met the inclusion criteria. BGCs were used in 1449 cases (58.4%) and were more frequently used with stent-retrievers (83.0%) than with contact aspiration (24.1%, p < 0.001). BGC-use was associated with higher rates of excellent recanalization (mTICI 2c–3) and first-pass success, particularly in stent-retriever cases ( p < 0.001), but not with good recanalization (mTICI 2b–3). No association was found with good 90-day functional outcome or any safety outcome ( p > 0.05). A numerically lower mortality rate was observed with BGCs (19.0% vs. 22.9%, p = 0.019), although this was not significant after adjustment. Conclusions BGC-use during EVT was associated with excellent recanalization and first-pass reperfusion, primarily in stent-retriever-treated patients. No significant impact on 90-day functional outcome nor on safety indicators was observed.