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Purpose Non-contrast CT (NCCT) is the most common initial imaging in the triage of acute ischemic stroke (AIS), and approximately 2/3 of large vessel occlusions (LVO) are hyperattenuating and measurable on NCCT. Mechanical thrombectomy (MT) is the standard of care AIS-LVO treatment, but disagreement on the most effective first-line thrombectomy technique remains, typically either aspiration (ADAPT) or combined stent-retriever/aspiration (CAPTIVE). We hypothesize that increasing clot length will modify first pass efficacy (FPE) and neurologic outcomes as a function of initial thrombectomy technique.Materials and Methods We performed a retrospective cohort analysis of patients who underwent MT for AIS-LVO from 2022-2024 at our comprehensive stroke center. Preprocedural NCCTs were manually reviewed for hyperattenuating thrombi, and clot length and attenuation values were measured. Patients were excluded if they had no visible hyperattenuating thrombus on NCCT, or if initial NCCT was technically inadequate or follow-up data was unavailable. The primary outcome measure was FPE. Secondary outcome measures included 90-day modified Rankin scale (mRS) scores and safety metrics, such as symptomatic intracranial hemorrhage (sICH). Generalized linear modeling was used to examine outcomes with binary (1/0) and Poisson (number of passes) distributions as a main effect and interaction effect (when appropriate).Results Eight-hundred forty-eight patients were screened, with 512 included. There was no evidence of a relationship between the likelihood of achieving FPE when using CAPTIVE as the first line technique (OR 1.009, 95%CI 0.976-1.042; p>0.05). There was a significant negative association between increasing clot length and likelihood of FPE with ADAPT (OR 0.935, 95%CI 0.889-0.984; p<0.05), with an inflection toward lower FPE likelihood at approximately 16 mm ( figure 1). For every 1 mm increase in clot length, the probability of achieving FPE with ADAPT decreased by 6.5%. Beyond the approximate threshold length, the use of CAPTIVE had a higher likelihood of FPE than ADAPT (p=0.014). ADAPT correlated with lower 90-day median mRS (3 [IQR 6-1], p=<0.001) for shorter clots, while the use of CAPTIVE correlated with lower mRS scores for longer clots (figure 2).Conclusion For AIS-LVO patients with hyperattenuating thrombi on initial NCCT, increasing visible clot length was correlated with a lower likelihood of FPE with ADAPT while FPE was not significantly modified by clot length when CAPTIVE was selected as the first line technique. Below a threshold value of approximately 16 mm, ADAPT was associated with superior 90d neurologic outcomes, while CAPTIVE was associated with superior outcomes above the threshold value.Disclosures M. Gonzales: None. R. Kim: None. G. Karayi: None. D. Hong: None. L. Bi: None. K. Moldovan: None. R. Torabi: None. E. Shaaya: None. G. Baird: None. M. Jayaraman: None. D.N. Wolman: None.Abstract O-018 Figure 1Abstract O-018 Figure 2