A balloon guiding sheath may include an elongated sheath comprising a proximal end, a distal end, an inner tube, an outer tube surrounding the inner tube, an access port, a distal port, and a working lumen extending through an interior portion of the elongated sheath between the access port and the distal port. The balloon guiding sheath may also include an inflatable balloon located on an outer surface of the elongated sheath adjacent the distal end. The balloon guiding sheath may include a plurality of inflation holes extending through a side wall of the elongated sheath. The elongated sheath may be sized and configured to enable direct insertion into a patient's vasculature through an arteriotomy in at least one of a femoral artery and vertebral artery to position the inflatable balloon at a target site.