Clinical and Procedural Outcomes with or without Balloon Guide Catheters during Endovascular Thrombectomy in Acute Ischemic Stroke: A Systematic Review and Meta-analysis with First-line Technique Subgroup Analysis

BACKGROUND: Balloon guide catheters are increasingly used to improve clot retrieval by temporarily stopping proximal blood flow during endovascular thrombectomy.

PURPOSE: Our aim was to provide a summary of the literature comparing the procedural and clinical outcomes of endovascular thrombectomy with or without balloon guide catheters, depending on the first-line technique used.

DATA SOURCES: We used PubMed/MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews.

STUDY SELECTION: We chose studies that compared using balloon guide catheters with not using them.

DATA ANALYSIS: Random effects meta-analysis was performed to compare the procedural outcomes measured as the first-pass effect, successful reperfusion, number of passes, procedural duration, arterial puncture to reperfusion time, distal emboli, and clinical outcomes.

DATA SYNTHESIS: Overall, a meta-analysis of 16 studies (5507 patients, 50.8% treated with balloon guide catheters and 49.2% without them) shows that the use of balloon guide catheters increases the odds of achieving a first-pass effect (OR = 1.92; 95% CI, 1.34–2.76; P < .001), successful reperfusion (OR = 1.85; 95% CI, 1.42–2.40; P < .001), and good functional outcome (OR =1.48; 95% CI, 1.27–1.73; P < .001). Balloon guide catheters reduce the number of passes (mean difference = −0.35; 95% CI, −0.65 to −0.04; P = .02), procedural time (mean difference = −19.73; 95% CI, −34.63 to −4.83; P = .009), incidence of distal or new territory emboli (OR = 0.5; 95% CI, 0.26–0.98; P = .04), and mortality (OR = 0.72; 95% CI, 0.62–0.85; P < .001). Similar benefits of balloon guide catheters are observed when the first-line technique was a stent retriever or contact aspiration, but not for a combined approach.

LIMITATIONS: The analysis was based on nonrandomized trials with a moderate risk of bias.

CONCLUSIONS: Current literature suggests improved clinical and procedural outcomes associated with the use of balloon guide catheters during endovascular thrombectomy, especially when using the first-line stent retriever.