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Combined balloon guide catheter, aspiration catheter, and stent retriever technique versus balloon guide catheter and stent retriever alone technique: a systematic review and meta-analysis
  1. Yao Neng Teo1,
  2. Ching-Hui Sia1,2,
  3. Benjamin Y Q Tan1,3,
  4. Jing Mingxue1,3,
  5. Bernard Chan1,3,
  6. Vijay Kumar Sharma1,3,
  7. Andrew Makmur1,4,
  8. Anil Gopinathan1,3,
  9. Cunli Yang1,3,
  10. Stanley Loh1,5,
  11. Sheldon Ng1,6,
  12. Shao Jin Ong1,5,
  13. Hock-Luen Teoh1,3,
  14. Rahul Rathakrishnan1,3,
  15. Tommy Andersson7,8,
  16. Fabian Arnberg9,
  17. Vamsi Krishna Gontu10,
  18. Tsong-hai Lee11,
  19. Volker Maus12,
  20. Lukas Meyer13,
  21. Pervinder Bhogal14,
  22. Oliver Spooner15,
  23. Tony YW Li1,2,
  24. Rodney YH Soh1,2,
  25. Leonard LL Yeo1,3
  1. 1 National University of Singapore, Singapore
  2. 2 Department of Cardiology, National University Heart Centre, Singapore
  3. 3 National University Health System, Singapore
  4. 4 Diagnostic Imaging, National University Hospital, Singapore
  5. 5 Department of Diagnostic Imaging, National University Health System, Singapore
  6. 6 Diagnostic Imaging, National University Health System, Singapore
  7. 7 Departments of Radiology and Neurology, AZ Groeninge, Kortrijk, Belgium
  8. 8 Department of Neuroradiology and Department of Clinical Neuroscience, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
  9. 9 Karolinska University Hospital, Stockholm, Sweden
  10. 10 Neuroradiology, Karolinska Universitetssjukhuset, Stockholm, Sweden
  11. 11 Stroke Center and Department of Neurology, Chang Gung Memorial Hospital Linkou Branch, Gueishan, Taoyuan, Taiwan
  12. 12 Knappschaftskrankenhaus Bochum Langendeer, Bochum, Germany
  13. 13 Diagnostic and Interventional Neuroradiology, Universitatsklinikum Hamburg Eppendorf Klinik und Poliklinik fur Neuroradiologische Diagnostik und Intervention, Hamburg, Germany
  14. 14 Royal London Hospital, London, UK
  15. 15 Department of Interventional Neuroradiology, Royal London Hospital, London, London, UK
  1. Correspondence to Dr Benjamin Y Q Tan, National University of Singapore NUHS towerblock 1E Kent Ridge Rd, Singapore, 119228, Singapore; benjamin_yq_tan{at}


Background The use of a combination of balloon guide catheter (BGC), aspiration catheter, and stent retriever in acute ischemic stroke thrombectomy has not been shown to be better than a stent retriever and BGC alone, but this may be due to a lack of power in these studies. We therefore performed a meta-analysis on this subject.

Methods A systematic literature search was performed on PubMed, Scopus, Embase/Ovid, and the Cochrane Library from inception to October 20, 2021. Our primary outcomes were the rate of successful final reperfusion (Treatment in Cerebral Ischemia (TICI) 2c–3) and first pass effect (FPE, defined as TICI 2c–3 in a single pass). Secondary outcomes were 3 month functional independence (modified Rankin Scale score of 0–2), mortality, procedural complications, embolic complications, and symptomatic intracranial hemorrhage (SICH). A meta-analysis was performed using RevMan 5,4, and heterogeneity was assessed using the I2 test.

Results Of 1629 studies identified, five articles with 2091 patients were included. For the primary outcomes, FPE (44.9% vs 45.4%, OR 1.04 (95% CI 0.90 to 1.22), I2=57%) or final successful reperfusion (64.5% vs 68.6%, OR 0.98 (95% CI 0.81% to 1.20%), I2=85%) was similar between the combination technique and stent retriever only groups. However, the combination technique had significantly less rescue treatment (18.8% vs 26.9%; OR 0.70 (95% CI 0.54 to 0.91), I2=0%). This did not translate into significant differences in secondary outcomes in functional outcomes, mortality, emboli, complications, or SICH.

Conclusion There was no significant difference in successful reperfusion and FPE between the combined techniques and the stent retriever and BGC alone groups. Neither was there any difference in functional outcomes, complications, or mortality.

  • thrombectomy
  • stent
  • stroke
  • catheter
  • technique

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information. Not applicable.

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Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information. Not applicable.

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  • YNT, C-HS and BYQT are joint first authors.

  • YNT, C-HS and BYQT contributed equally.

  • Contributors YNT, C-HS, and BYQT: search terms and literature review, draft manuscript, statistical analysis, and editing. BC, VKS, H-LT, TA, FA, VKG, TH-L, VM, LM, PB, and OS: direction of research and editing. JM, AM, AG, CY, SL, SN, SJO, and RR: literature review and editing. TYWL and RYHS: statistical analysis and editing. LLLY: direction of research, search terms and literature review, draft manuscript, statistical analysis, and editing. LLLY is the author responsible for the overall content as the guarantor.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial, or not-for-profit sectors.

  • Competing interests LM received compensation as a speaker for Balt.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.