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Introduction Techniques for endovascular thrombectomy in acute ischemic stroke due to medium or distal vessel occlusions (MDVO) need to be improved, and first-line aspiration is emerging as a promising technique.Aim of Study The objective of this study was to describe first-pass and final reperfusion rates with a triaxial direct aspiration first pass technique (ADAPT) and a novel, quadriaxial technique (QUATTRO-ADAPT, see figure 1) using RED43 Reperfusion Catheters to target MDVOs.Method This retrospective study collected data from 11 stroke centers in Europe and North America between 2023 and 2025. Patients with primary, isolated MDVOs who underwent thrombectomy using first-line aspiration with RED43 Reperfusion Catheters were included. Primary outcome was first-pass successful reperfusion rate (mTICI 2b-3). Additionally, final reperfusion rates, complications and functional outcomes up to 90 days were evaluated.Abstract A304 Figure 1Results We included 85 cases in our analysis. Median age was 74 (IQR 67–81) years and median NIHSS score 9 points (IQR 6–15). The majority (69.4%) had an occlusion of the co- or nondominant M2 segment of the middle cerebral artery. Successful first-pass reperfusion was 63.5% overall, with 55.6% for the triaxial ADAPT and 69.4% for the quadriaxial QUATTRO-ADAPT. Final successful reperfusion was achieved in 96.5%. Complications included vessel perforations (2.4%), subarachnoid hemorrhage (3.5%), parenchymal hematoma type 2 (2.4%), and symptomatic intracerebral hemorrhage (1.2%). Functional independence (mRS 0–2) at 90 days was observed in 58.7%.Conclusion This study shows that first-line aspiration, especially in a quadriaxial approach, can be effective and safe. These findings should be evaluated in prospective trials.Conflict of Interest Yes MP: Grants from the Swiss National Science Foundation (SNF) for the DISTAL trial (33IC30_198783), ICARUS (32003B_220118) and TECNO trial (32003B_204977), Grant from Bangerter-Rhyner Stiftung for the DISTAL trial. Unrestricted Grants for the DISTAL trial from Stryker Neurovascular Inc., Medtronic Inc., Phenox GmbH, Penumbra Inc. and Rapid Medical Inc., Sponsor-PI SPINNERS trial (Funded by a Siemens Healthineers AG Grant), Research agreement with Siemens Healthineers AG, Local PI for the ASSIST, EXCELLENT, TENSION, COATING, SURF and ESCAPE-NEXT trials. Speaker fees: Stryker Neurovascular Inc., Medtronic Inc., Penumbra Inc., Acandis GmbH, Phenox GmbH, Siemens Healthineers AG. VA, AA, AB, NN and NR: nothing to disclose.