Background <p>Vascular angulation at the level of occlusion negatively affects the success of aspiration thrombectomy in patients with acute ischemic stroke (AIS). This study aims to evaluate the efficacy of the aspiration thrombectomy with microcatheter navigation (ATMN) technique in AIS patients where the direct aspiration first pass technique (DAPT) failed due to vascular angulation at the occlusion level.</p> Methods <p>The patients admitted to our institution with AIS due to large vessel occlusion and treated with DAPT as a first-line technique between August 2020 and December 2022 were retrospectively evaluated. The feasibility and success of the ATMN technique in patients with DAPT failure were evaluated. Vascular angulation at the occlusion level was measured and compared.</p> Results <p>43 patients were included in the study. Successful revascularization was achieved with DAPT in 29 of 43 patients (67.5%). ATMN technique was performed on 14 of 43 patients (32.5%) after DAPT failure. The ATMN technique achieved a high success rate, with 78.5% (11 out of 14) of patients experiencing successful recanalization. The mean vascular angulation at the occlusion level was significantly increased in patients with sufficient recanalization by DAPT as first-line therapy compared to the patients with insufficient recanalization by DAPT who underwent successful thrombectomy with the ATMN technique (143.5 ± 23.3 vs. 107.6 ± 15.6, p ˂ 0.001).</p> Conclusion <p>This study’s results showed that the ATMN technique was a useful alternative with a high level of success in stroke patients with vascular angulation in which DAPT failed to achieve sufficient recanalization.</p>