Background Our initial experience using the two-stage aspiration technique (TSAT) with proximal flow arrest by a balloon guiding catheter is presented. In TSAT, aspiration is applied with the 5MAX ACE and also with the 3MAX catheter with a Penumbra aspiration pump, while arresting proximal flow by balloon inflation.

Methods In patients treated with TSAT, clinical data including National Institutes of Health Stroke Scale (NIHSS) score at admission and the modified Rankin Scale (mRS) score at discharge, as well as procedural data including the Thrombolysis in Cerebral Infarction (TICI) score, procedural time, and complications were analyzed.

Results Thirty-four consecutive patients (19 men (56%); mean age 73 years) were treated with TSAT using a balloon guiding catheter. The patients presented with a mean NIHSS score of 17.4 and 23 (68%) patients received IV tissue plasminogen activator. Median time from groin puncture to successful recanalization was 41 min (range 15–160 min). All patients were successfully revascularized; TICI 2b or better recanalization was achieved in 30 (88%) patients. No patient required an additional procedure such as use of a stent retriever. Procedure-related complications occurred in two (5.9%) patients (vessel injury and guidewire perforation). Symptomatic intracranial hemorrhage occurred in one patient and asymptomatic hemorrhagic infarction occurred in two patients. There were no cases of embolization to new territory (ENT). The mean NIHSS score at discharge improved to 6.1. Sixteen patients (47%) achieved a good outcome with an mRS score of 0–2 at discharge (mean hospitalization period 20 days).

Conclusions TSAT with proximal flow arrest by a balloon guiding catheter is an effective and safe method to achieve good clinical and angiographic outcomes. This method may reduce ENT in the direct aspiration first-pass thrombectomy (ADAPT) technique.