A balloon guiding sheath, comprising: an elongated sheath comprising a proximal end, a distal end, an inner tube extending between the proximal end and the distal end, an outer tube surrounding the inner tube and extending between the proximal end and the distal end, an access port located adjacent the proximal end, a distal port located adjacent the distal end, and a working lumen extending through an interior portion of the elongated sheath between the access port and the distal port; an inflatable balloon located on an outer surface of the elongated sheath adjacent the distal end, the inflatable balloon being fluidly coupled to an inflation lumen extending between the inflatable balloon and an inflation port located adjacent the proximal end; and a plurality of inflation holes (38,80,82) extending through a side wall of the elongated sheath, wherein the plurality of inflation holes (38,80,82) fluidly couple the inflatable balloon to the inflation lumen, wherein the elongated sheath is sized and configured to enable direct insertion into a patient's vasculature through an arteriotomy in at least one of a carotid artery or a vertebral artery to position the inflatable balloon at a target site, further comprising an inflation trough defined by the outer tube, wherein the inflation trough facilitates fluid coupling between the plurality of inflation holes (38,80,82), wherein the elongated sheath is elongate along a first direction, the plurality of inflation holes (38,80,82) each define a first width extending along the first direction, and the inflation trough defines a second width extending along the first direction, and wherein the first width is greater than the second width. an elongated sheath comprising a proximal end, a distal end, an inner tube extending between the proximal end and the distal end, an outer tube surrounding the inner tube and extending between the proximal end and the distal end, an access port located adjacent the proximal end, a distal port located adjacent the distal end, and a working lumen extending through an interior portion of the elongated sheath between the access port and the distal port; an inflatable balloon located on an outer surface of the elongated sheath adjacent the distal end, the inflatable balloon being fluidly coupled to an inflation lumen extending between the inflatable balloon and an inflation port located adjacent the proximal end; and a plurality of inflation holes (38,80,82) extending through a side wall of the elongated sheath, wherein the plurality of inflation holes (38,80,82) fluidly couple the inflatable balloon to the inflation lumen, wherein the elongated sheath is sized and configured to enable direct insertion into a patient's vasculature through an arteriotomy in at least one of a carotid artery or a vertebral artery to position the inflatable balloon at a target site, further comprising an inflation trough defined by the outer tube, wherein the inflation trough facilitates fluid coupling between the plurality of inflation holes (38,80,82), wherein the elongated sheath is elongate along a first direction, the plurality of inflation holes (38,80,82) each define a first width extending along the first direction, and the inflation trough defines a second width extending along the first direction, and wherein the first width is greater than the second width.