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Background Aspiration thrombectomy is a cornerstone treatment for acute ischemic stroke (AIS) due to large vessel occlusion. Increasing catheter inner diameter has been proposed to enhance clot ingestion and improve first-pass reperfusion. Super-large-bore (SLB) aspiration catheters represent the latest evolution in device design; however, their incremental clinical benefit over standard large-bore (LB) catheters remains uncertain. We performed a systematic review and meta-analysis to compare the safety and effectiveness of LB versus SLB aspiration catheters.Methods A systematic literature search identified studies reporting outcomes of mechanical thrombectomy using LB and SLB aspiration catheters. Both single-arm and comparative studies were included. The primary outcome was first-pass mTICI2C effect (FPE; mTICI ≥2C on first pass). Secondary outcomes included safety and procedural outcomes. Random-effects models were used to generate pooled estimates. Subgroup analyses compared LB and SLB cohorts, and sensitivity analyses included leave-one-out and outlier exclusion approaches.Results A total of 3,966 patients (41single arm studies) were included in the primary analyses (SLB n=376; LB n=3,590), with sample sizes varying across outcomes based on study-level reporting. First-pass effect (mTICI ≥2C) was comparable between SLB and LB catheters (56% [95% CI: 43%-68%] vs 50% [95%CI: 41%-59%]; p=0.4). Final successful recanalization rates were high and similar in both groups (92% vs 92%; p=0.9). Procedural time did not differ, with pooled mean times of 27.03 minutes (95% CI 18.85-35.21) for SLB and 26.97 minutes (95% CI 21.91-32.03) for LB catheters (p=0.99). The need for rescue therapy showed a trend toward lower use with SLB compared with LB catheters (11% vs 20%; p=0.06). Rates of failure to reach the target clot showed a trend to higher rates in the SLB group (10% vs. 5%; p=0.11). Safety outcomes did not differ significantly, including distal embolization (9% vs 4%; p=0.2) and sICH (4% vs 6%; p=0.2). Clinical outcomes were limited by sparse reporting in the SLB group, precluding robust pooled comparisons. Sensitivity analyses did not change the primary findings. Conclusions Super-large-bore aspiration catheters do not demonstrate a significant advantage over large-bore catheters in first-pass reperfusion or final recanalization. Safety outcomes were comparable between groups, with a non-significant trend toward increased failure to reach the clot with SLB and reduced need for rescue therapy. The absence of adequately reported clinical outcomes limits conclusions regarding functional benefit. Current evidence does not support a clear clinical advantage of increased catheter caliber, and further prospective comparative studies with standardized outcome reporting are needed.Disclosures N. Goyal: None. L. Saada: None. D. Hijazi: None. T. Ma: None. R. Grandhi: None.Abstract E-349 Figure 1