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 extending through a side wall of the elongated sheath , wherein the plurality of inflation holes 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 , wherein the elongated sheath is elongate along a first direction, the plurality of inflation holes 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 extending through a side wall of the elongated sheath , wherein the plurality of inflation holes 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 , wherein the elongated sheath is elongate along a first direction, the plurality of inflation holes 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 . <EOS>