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Introduction/Purpose Catheter-mediated (Dotter) angioplasty using Tenzing (as known as Tenzingplasty) has been recently described as a promising endovascular treatment of intracranial atherosclerotic disease (ICAD). 1 Tenzing (Route 92 Medical, San Mateo, CA), is a shelf-reducing delivery catheter that has an atraumatic tapered distal tip that progressively enlarges to maximal outer diameter of 1.2mm (Tenzing 5), 1.6mm (Tenzing 7), and 2.1mm (Tenzing 8). These Tenzing OD approximate commonly used balloon microcatheter diameters used for arterial angioplasty. We hypothesize that Tenzingplasty results in decreased utilization of balloon angioplasty catheters in preparation for stenting of ICAD lesions, in both the elective and emergent (LVO rescue) settings.Materials/Methods After IRB approvals, we retrospectively reviewed clinical and procedural data of patients with underlying ICAD treated with off-label Tenzingplasty followed by stenting from 2022-2025, either as part of endovascular treatment for large vessel occlusion, or electively after maximal medical therapy failure.Results We identified 21 consecutive symptomatic ICAD patients that met the inclusion criteria in our prospectively maintained institutional databases. The median (IQR) age of the patients was 62 (58-65) years, and 66% were male. ICAD locations were: M1 (12), M2 (2), ICA (3), vertebral V4 segment (3), basilar (1). Aspiration thrombectomy as a first pass approach for initial mTICI 0 (without crossing ICAD lesion) was performed in 10/21 (48%). After median 1 (IQR 1-2) Tenzingplasty pass, median (IQR) stenosis improved from 90% (83-99) to 70% (55-76) post-Tenzingplasty (p< 0.0001). Subsequent balloon angioplasty was performed in 3/21 (14%) using a Gateway (Stryker, Fremont, CA) balloon microcatheter. There was one Tenzingplasty-related complication (a non-flow limiting dissection) and there were no perforations. Post-stenting, there was no significant difference in residual stenosis using Atlas vs Wingspan/balloon-mounted coronary stents (eg Onyx Frontier, BES Synergy) (73% vs 70%, p=0.35). In follow up, 57% had a 90-day mRS of 0-2.Conclusion Tenzingplasty improves luminal caliber and significantly reduces the need for balloon angioplasty prior to stenting of ICAD. Further study is warranted.Reference Settecase F, Caldwell J, Pervez M, et al. Intracranial dotter angioplasty using tenzing (Tenzingplasty) for acute ischemic stroke with underlying intracranial atherosclerotic disease. Journal of NeuroInterventional Surgery Published Online First: 27 June 2025. doi: 10.1136/jnis-2025-023663Disclosures F. Settecase: 1; C; Medtronic, Stryker, Terumo-Microvention. 2; C; Route 92 Medical; Stryker; Rapid.ai. 4; C; Route 92 Medical. R. Khangura: None. A. Baker: 2; C; Route 92 Medical; Hyperfine Inc. 6; C; DSMB Route 92 Medical. K. Warren: 2; C; Route 92 Medical. 4; C; Route 92 Medical. M. Alexander: 2; C; Route 92 Medical. 4; C; Route 92 Medical, Piraeus, Certus Critical Care. M. Pervez: None. J. English: 2; C; Stryker. 4; C; Route 92 Medical. 5; C; Route 92 Medical. G. Dabus: 2; C; Route 92, Medtronic, Microvention, Penumbra, Stryker, Viz.Ai, Glide Healthcare, Cerenovus. 6; C; Co-PI SUMMIT MAX, MARRS.Abstract E-071 Figure 1