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Original research
Comparison of balloon guide catheter versus non-balloon guide catheter for mechanical thrombectomy in patients with distal medium vessel occlusion
  1. Atakan Orscelik1,2,
  2. David F Kallmes1,
  3. Cem Bilgin1,
  4. Basel Musmar1,
  5. Yigit Can Senol1,
  6. Hassan Kobeissi1,
  7. Sameh Samir Elawady2,
  8. Conor Cunningham2,
  9. Hidetoshi Matsukawa2,3,
  10. Sara Zandpazandi2,
  11. Mohammad-Mahdi Sowlat2,
  12. Ilko Maier4,
  13. Sami Al Kasab2,
  14. Pascal Jabbour5,
  15. Joon-tae Kim6,
  16. Stacey Q Wolfe7,
  17. Ansaar Rai8,
  18. Robert M Starke9,
  19. Marios-Nikos Psychogios10,
  20. Edgar A Samaniego11,
  21. Adam S Arthur12,
  22. Shinichi Yoshimura3,
  23. Hugo Cuellar13,
  24. Brian M Howard14,
  25. Ali Alawieh14,
  26. Daniele G Romano15,
  27. Omar Tanweer16,
  28. Justin Mascitelli17,
  29. Isabel Fragata18,
  30. Adam J Polifka19,
  31. Joshua W Osbun20,
  32. Roberto Javier Crosa21,
  33. Charles Matouk22,
  34. Min S Park23,
  35. Michael R Levitt24,
  36. Mark Moss25,
  37. Travis M Dumont26,
  38. Richard Williamson27,
  39. Pedro Navia28,
  40. Peter Kan29,
  41. Reade De Leacy30,
  42. Shakeel A Chowdhry31,
  43. Mohamad Ezzeldin32,
  44. Alejandro M Spiotta2,
  45. Waleed Brinjikji1
  46. On behalf of the STAR Collaborators
  1. 1Department of Radiology, Mayo Clinic Rochester, Rochester, Minnesota, USA
  2. 2Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
  3. 3Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
  4. 4Department of Neurology, University Medicine Goettingen, Goettingen, NS, Germany
  5. 5Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
  6. 6Department of Neurology, Chonnam National University Hospital, Gwangju, Gwangju, Korea (the Republic of)
  7. 7Department of Neurosurgery, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
  8. 8Department of Radiology, West Virginia University Hospitals, Morgantown, West Virginia, USA
  9. 9Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
  10. 10Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
  11. 11Department of Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
  12. 12Department of Neurosurgery, University of Tennessee Health Science Center/Semmes Murphey Foundation, Memphis, Tennessee, USA
  13. 13Department of Neurosurgery, Louisiana State University Health Shreveport, Shreveport, Louisiana, USA
  14. 14Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
  15. 15Department of Neuroradiology, University Hospital 'San Giovanni di Dio e Ruggi d’Aragona', Salerno, Italy
  16. 16Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
  17. 17Department of Neurosurgery, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
  18. 18Department of Neuroradiology, Centro Hospitalar de Lisboa Central, Lisboa, Portugal
  19. 19Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
  20. 20Department of Neurosurgery, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
  21. 21Department of Endovascular Neurosurgery, Médica Uruguaya, Montevideo, Montevideo, Uruguay
  22. 22Department of Neurosurgery, Yale University, New Haven, Connecticut, USA
  23. 23Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
  24. 24Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
  25. 25Department of Interventional Neuroradiology, Washington Regional Medical Center, Fayetteville, Arkansas, USA
  26. 26Department of Surgery, Division of Neurosurgery, University of Arizona/Arizona Health Science Center, Tucson, Arizona, USA
  27. 27Department of Neurology, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
  28. 28Department of Interventional and Diagnostic Neuroradiology, Hospital Universitario La Paz, Madrid, Spain
  29. 29Department of Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
  30. 30Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
  31. 31Department of Neurosurgery, North Shore University Health System, Evanston, Illinois, USA
  32. 32Department of Clinical Sciences, University of Houston, HCA Houston Healthcare, Kingwood, Texas, USA
  1. Correspondence to Dr Atakan Orscelik, Department of Radiology, Mayo Clinic Rochester, Rochester, Minnesota, USA; orscelik{at}


Background Several studies have established the safety and efficacy of balloon guide catheters (BGCs) for large vessel occlusions. However, the utility of BGCs remains largely unexplored for distal medium vessel occlusions (DMVOs). In this study, we aim to compare the outcomes of BGC vs. Non-BGC in patients undergoing mechanical thrombectomy (MT) for DMVO.

Method This retrospective study from the Stroke Thrombectomy and Aneurysm Registry (STAR) encompassed adult patients with acute anterior cerebral artery, posterior cerebral artery, and middle cerebral artery-M2–3–4 occlusions. Procedure times, safety, recanalization, and neurological outcomes were compared between the two groups, with subgroup analysis based on first-line thrombectomy techniques.

Results A total of 1508 patients were included, with 231 patients (15.3%) in the BGC group and 1277 patients (84.7%) in the non-BGC group. The BGC group had a lower modified Thrombolysis in Cerebral Infarction (mTICI) score ≥2C (43.2% vs 52.7%, P=0.01), longer time from puncture to intracranial access (15 vs 8 min, P<0.01), and from puncture to final recanalization (97 vs 34 min, P<0.01). In the Solumbra subgroup, the first pass effect (FPE) rate was lower in the BGC group (17.4% vs 30.7%, P=0.03). Regarding clinical outcomes, the BGC group had a lower rate of distal embolization (8.8% vs 14.9%, P=0.03).

Conclusion Our study found that use of BGC in patients with DMVO was associated with lower mTICI scores, decreased FPE rates, reduced distal embolization, and longer procedure times.

  • Balloon
  • Stroke
  • Thrombectomy
  • Technology

Data availability statement

Data are available upon reasonable request. The data that support the findings of this study are available from the principal investigator upon reasonable request.

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Data availability statement

Data are available upon reasonable request. The data that support the findings of this study are available from the principal investigator upon reasonable request.

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  • Contributors WB, DFK and AO contributed to the conception and design of the study. All authors were responsible for data collection. SSE and AO performed statistical analyses. All authors were involved in the interpretation of results, drafting of the article, critical revision of the article, and final approval of the version to be published. AO is responsible for the overall content as 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 The STAR Registry currently receives funding from Penumbra, Stryker, and Medtronic. HM received a lecture fee from Daiichi-Sankyo and Stryker and consulting services fee from B Braun. SY received a lecture fee from Stryker, Medtronic, Johnson and Johnson, Kaneka Medics. IM: speakers honoraria from Pfizer and Bristol-Myers Squibb. SAK: grant from Stryker for RESCUE-ICAS Registry. RMS: research is supported by the NREF, Joe Niekro Foundation, Brain Aneurysm Foundation, Bee Foundation, Department of Health Biomedical Research Grant (21K02AWD-007000), and by National Institute of Health (R01NS111119-01A1) and (UL1TR002736, KL2TR002737) through the Miami Clinical and Translational Science Institute, from the National Center for Advancing Translational Sciences and the National Institute on Minority Health and Health Disparities. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH; has an unrestricted research grant from Medtronic and Balt and has consulting and teaching agreements with Penumbra, Abbott, Medtronic, Balt, InNeuroCo, Cerenovus, Naglreiter, Tonbridge, Von Medical, and Optimize Vascular. M-NP: grants from the Swiss National Science Foundation (SNF) for the DISTAL trial (33IC30_198783) and TECNO trial (32003B_204977), grant from Bangerter-Rhyner Stiftung for the DISTAL trial; unrestricted grants for the DISTAL trial from Stryker Neurovascular Inc, Phenox GmbH, Penumbra Inc, and Rapid Medical Inc., Sponsor-PI SPINNERS trial (funded by a Siemens Healthineers AG Grant); research agreement with Siemens Healthineers AG, Local PI for the ASSIST, EXCELLENT, TENSION, COATING, SURF and ESCAPE-NEXT trials; speaker fees: Stryker Neurovascular Inc., Medtronic Inc., Penumbra Inc, Acandis GmbH, Phenox GmbH, Siemens Healthineers AG. ASA: consultant for Arsenal, Balt, Johnson and Johnson, Medtronic, Microvention, Penumbra, Perfuze, Scientia, Siemens, Stryker; research support from Balt, Medtronic, Microvention, Penumbra, and Siemens; shareholder Azimuth, Bendit, Cerebrotech, Endostream, Magneto, Mentice, Neurogami, Neuros,Perfuze, Revbio, Scientia, Serenity, Synchron, Tulavi, Vastrax, VizAI. SY: lecture fee from Stryker, Medtronic, Johnson and Johnson, Kaneka Medics. HC: consultant for Medtronic, Penumbra, and Microvention. JAG: grant support from Georgia Research Alliance, Emory Medical Care Foundation, Neurosurgery Catalyst, Consultant: Cognition, Imperative Care. DGR: consultant for Penumbra, Balt, Microvention, Phenox. CM: consultant for Stryker, Medtronic, Microvention, Penumbra, and Silk Road Medical; speaker for Penumbra and Silk Road Medical Contact PI for NIH Grant R21NS128641. MSP: consultant for Medtronic. MRL: unrestricted educational grants from Medtronic and Stryker; consulting agreement with Medtronic, Aeaean Advisers, and Metis Innovative; equity interest in Proprio, Cerebrotech, Apertur, Stereotaxis, Fluid Biomed, and Hyperion Surgical; editorial boards of Journal of NeuroInterventional Surgery and Frontiers in Surgery. RW: consultant for Medtronic, Stryker, and Synaptive Medical. PN: consultant for Penumbra, Medtronic, Stryker, Cerenovus and Balt; grants from the NIH (1U18EB029353-01) and unrestricted educational grants from Medtronic and Siemens; consultant for Imperative Care and Stryker Neurovascular; stock ownership in Vena Medical. RDL: PI for Imperative Trial; research grants from Siemens Healthineers and Kaneka Medical; consultant for Cerenovus, Stryker Neurovascular and Scientia Vascular; minor equity interest Vastrax, Borvo Medical, Synchron, Endostream, Von Vascular. SAC: consultant and proctor for Medtronic and Microvention. AMS: research support from Penumbra, Stryker, Medtronic, Rapid AI, Avail; consultant for Penumbra, Stryker, Terumo, and RapidAI Equity Avail. WB: equity in Nested Knowledge, Superior Medical Editors, Piraeus Medical, Sonoris Medical, and MIVI Neurovascular; receives royalties from Medtronic and Balloon Guide Catheter Technology; receives consulting fees from Medtronic, Stryker, Imperative Care, MicroVention, MIVI Neurovascular, Cerenovus, Asahi, and Balt; serves in a leadership or fiduciary role for MIVI Neurovascular, Marblehead Medical LLC, Interventional Neuroradiology (editor-in-chief), Piraeus Medical, and WFITN.

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

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