Background: A direct aspiration technique recently approved to be not inferior to stent retrieval as a mechanical thrombectomy for acute ischemic stroke patients with a large vessel occlusion. Few reports use distal access catheters for aspiration.
Objectives: Our study aims to evaluate distal access catheters as a first pass approach of thrombus aspiration for safety and efficacy.
Patients and methods: Forty patients with acute stroke due to large vessel occlusion have been divided into aspiration thrombectomy group in which thrombectomy is done by aspiration and control group which receive medical treatment only. Prospective functional outcomes and complications are compared between both groups.          
Results: Successful revascularization was achieved in 10 /20 (50%) of patients with aspiration thrombectomy as stand-alone and in 18 /20 (90%) of patients when adding stent retrieval as a rescue maneuver. Functional independence at 90 days was achieved on 9/20 (45%) patients with aspiration versus 2/20 (10%) patients of control group; P = 0.015, While Mortality with aspiration is less than control group 4/20 (20%) versus 9/20 (45%) respectively P = 0.088. Spontaneous intracerebral hemorrhage has occurred in 3/20 (15%) patients with aspiration versus 4/20 (20%) patients in the control group. One patient had carotid dissection as a complication of thrombectomy. 
Conclusion: Our study demonstrates that aspiration thrombectomy by distal access catheters is easily manipulating, safe, and have fewer complications. Aspiration reveals a significant difference regarding functional independence at three months and despite less mortality with aspiration, there is an insignificant difference between both groups.