Abstract Purpose Specific decisions made by neurointerventionists are often lost behind the data of large-scale trials, and many of these studies have taken place before the development of new techniques and devices. This study compares the stent-retriever assisted vacuum-locked extraction (SAVE) technique with a direct aspiration first pass (ADAPT), as well as the use of a balloon guide catheter (BGC), in intracranial internal carotid artery (IC-ICA) occlusions. Methods Observational and retrospective study from an Italian hospital, including patients who underwent thrombectomy for IC-ICA occlusion between 1 January 2019 and 31 March 2021. Results Out of 91 IC-ICA occlusions, the ADAPT was the first choice in 20 (22%) and the SAVE in 71 (78%). A BGC was used in 32 (35%) cases, always in conjunction with the SAVE technique. The use of SAVE technique without BGC was associated with the least risk of distal embolization (DE) in the territory occluded (44% vs. 75% when ADAPT technique was used; p = 0.03) and achieved first pass effect (FPE) more frequently (51% vs. 25%, p = 0.09). When the SAVE technique was used, BGC (BGC-SAVE) compared to no BGC (NoBGC-SAVE) was associated with a tendency for less DE (31% vs. 44%, p = 0.3), more FPE (63% vs. 51%, p = 0.5), the same median number of passes (1, p = 0.8) and similar groin-to-recanalization times (36.5 vs. 35.5 min, p = 0.5), none of which reached statistical significance. Conclusion Our findings support the use of SAVE technique for IC-ICA occlusions; the added benefit of BGC compared to long sheaths was not remarkable in this sample.