Background: Acute anterior circulation large vessel occlusion (ACLVO) strokes represent a critical challenge in stroke management. Advancements in thrombectomy strategies, including contact aspiration (CA), stent retrievers (SR), and their combination (SRA), particularly with the addition of balloon guide catheters (BGC), aim to enhance outcomes. This systematic review and Bayesian network meta-analysis evaluates the efficacy and safety of these first-line thrombectomy strategies. Methods: A systematic search was performed across nine databases up to March 15, 2025, yielding 44 studies with 19 268 participants. The risk of bias was assessed using RoB 2.0 for randomized controlled trials and ROBINS-I for observational studies. Bayesian random-effects network meta-analysis was conducted, presenting odds ratios (OR) with 95% CIs and ranking interventions via surface under the cumulative ranking curve (SUCRA). Outcomes included recanalization success (modified Thrombolysis in Cerebral Infarction (mTICI) 2b-3), first-pass effect (FPE), functional independence (modified Rankin Scale ≤2 at 90 days), symptomatic intracranial hemorrhage (sICH), and 90-day mortality. Results: SRA+BGC was most effective for achieving mTICI 2b-3 (OR 2.87, 95% CI 1.64 to 5.20, SUCRA 90.1) and FPE (OR 7.33, 95% CI 1.71 to 39.71, SUCRA 91.0). CA+BGC yielded the highest odds of functional independence at 90 days (OR 1.96, 95% CI 1.16 to 3.41, SUCRA 88.1) and the lowest 90-day mortality (OR 0.42, 95% CI 0.20 to 0.95). Safety outcomes favored SR+BGC and SRA+BGC for reducing sICH (OR 0.59, 95% CI 0.37 to 0.91, SUCRA 85.3). CA alone was associated with significant improvements over SR in functional outcomes (OR 1.41, 95% CI 1.09 to 1.83, SUCRA 78.5), but SRA alone was linked to higher mortality (OR 1.74, 95% CI 1.06 to 2.66). Conclusion: Thrombectomy strategies incorporating BGC, particularly CA+BGC and SRA+BGC, achieve superior efficacy and safety outcomes in patients with acute ACLVO stroke. © Author(s) (or their employer(s)) 2025. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ Group.