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Introduction While distal access catheters are an infrequent focus of technical reports, they remain a mainstay in the treatment of complex intracranial pathologies. There have been reports suggesting that modern large-bore guide catheters can be safely advanced intracranially; however, emerging stroke literature suggests that aggressive distal positioning may impart underrecognized hemodynamic stress on collateral networks. Achieving safe distal access with an intermediate support catheter may reduce the need for intracranial guide positioning. Here, we critically evaluate our experience using the 127-cm Socrates 38 catheter (Scientia Vascular, Park City, UT) in a dedicated intracranial support role.Methods Prospectively maintained procedural databases at 8 institutions were queried for procedures where the Socrates 38 was used as an intermediate catheter during an interventional procedure. Patient demographics and procedural parameters were analyzed, as were safety and effectiveness outcomes. Data were summarized using descriptive statistics.Results Ninety-eight procedures were identified including: intracranial aneurysm embolization (n=40; ruptured aneurysm coiling [10] and intrasaccular flow diversion [3]; unruptured aneurysm coiling [14], intravascular flow diversion [4], and intrasaccular flow diversion [9]), intracranial vascular malformation embolizations (n=20; ruptured arteriovenous malformations [9], unruptured arteriovenous malformations [5], and unruptured dural arteriovenous fistulas [6]), external carotid artery embolizations (n=35; middle meningeal artery embolizations [28], oral bleeding/epistaxis [4], tumor embolizations [3]), venous interventions (2) and a spinal dural fistula embolization (1).A triaxial access system was used in 97 of 98 procedures (99%), and the target distal location was reached with the Socrates 38 catheter in 96 of 98 procedures (98%). Coaxial microcatheters ranged in outer diameter from 2.1 to 2.6Fr. No device-related adverse events or device damage were reported. Complications unrelated to the intermediate catheter occurred in 4 procedures (4%). For ICA distribution procedures (n=46), the base catheter was positioned in the extracranial ICA in 30 cases (65%) and in the skull base/transitional segments (C2-4) in 16 cases (35%). The distal-most location of the Socrates 38 during these procedures was the skull base/transitional ICA (n=6), intracranial ICA (n=12), M1 segment (n=9), M2 segment (n=4), M3 segment (n=4), A1 segment (n=9), A2 segment (n=1), and A3 segment (n=1).For vertebrobasilar distribution procedures (n=7), the base catheter was positioned in the V1 or V2 segment in 6 cases (86%). Distal most location of the Socrates 38 during these procedures was the V4 segment (n=3), basilar artery (n=2), PICA (n=1), and P2 segment of the PCA (n=1). For middle meningeal artery embolization procedures (n=28), the base catheter was positioned in the ECA in 26 procedures (93%), with the distal-most location of the Socrates 38 in the extracranial middle meningeal artery in most procedures (n=17, 65%).Conclusion In this series, the Socrates 38 frequently enabled safe distal intracranial support despite proximal guide catheter positioning, suggesting its utility as a depth-substitution strategy. All complications were consistent with pathology-specific risks, and none were attributable to the intermediate catheter.Additional Information Acknowledgements The Segal Family Foundation provides grant support for the Segal Family Internship in Cerebrovascular Medicine.Disclosures M. Lavieri: None. I. Maiewski: None. K. Shah: None. R. Singh: None. B. Gross: None. A. Al-Bayati: None. C. Hawkins: None. V. Doss: None. E. Quach: None. B. Jankowitz: None. J. Haimi: None. D. Giurgiutiu: None. D. Babici: None.