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Mechanical thrombectomy (MT) has become the standard treatment for large vessel occlusion (LVO) in acute ischemic stroke (AIS) in well-selected patients. Although many devices and strategies exist, use of a balloon-tip guide catheter (BGC) in conjunction with stent-retriever (SR) may hold many advantages. We aim to assess the efficacy and identify predictors of technical success of this unique approach.We reviewed our prospectively maintained database to identify 93 consecutive cases in which a BGC was used for MT in anteriorcirculation LVO, between February 2015 and September 2016. Various preprocedural and intraprocedural variables were recorded in addition to technical and clinical outcome measures. Predictors of technical and clinical outcome were identified by univariate and multivariable logistic regression analysis.Successful recanalization of the LVO (mTICI=2b) was achieved in 86.9% (n=80) of cases, including a first-pass success rate of 52.7% (n=49) and complete revascularization of mTICI 3 in 56.5% (n=52) of cases. Average time from groin puncture to reperfusion was 67.9 minutes. The M1 segment was the most common location of the occlusive thrombus (64.5%, n=60). Preoperative IV-tPA was administered in 55.9% (n=52) of cases and 48.4% (n=45) were functionally independent (mRS<=3) at last follow-up. Middle cerebral artery location was strongly predictive of first-pass success resulting in a TICI =2b revascularization (OR 7.10, p=0.018). Preoperative tPA bolus was a predictor of successful first pass (OR 2.88, p=0.017). Intraoperative IA-tPA administration showed increased incidence of post-operative hemorrhagic conversion (OR 4.12, p=0.018). Patients <65 years old were more likely to develop subsequent emboli (OR 2.83, p=0.053). Hemorrhagic conversion (OR 8.33, p=0.001), female gender (OR 2.85, p=0.042), and decreasing mTICI were associated with a poor clinical outcome (mRS>=4; OR 1.76, p=0.008).BGC use in MT results in a high rate of technical success and excellent clinical outcome in anterior circulation LVOs. While the optimal strategy for performing thrombectomy is unclear, our data suggest BGC in combination with SR may be most effective in removing MCA clots.