Small trials (VAST, VIST) did not show a clear benefit for vertebral artery stenting, and a recent combined analysis also did not demonstrate clear benefit for vertebral artery stenting compared with medical therapy. Recommendation-Specific Supportive Text 1. On the basis of trials of antiplatelet therapy for patients with recent stroke or TIA, antiplatelet ther- apy is recommended for patients with symptomatic vertebral artery stenosis. Similarly, antihypertensive therapy and statins are recommended for patients with symptomatic vertebral artery stenosis. The use of multimodality medical therapy also has been incorporated into clinical trials.378 CLINICAL STATEMENTS AND GUIDELINES Kleindorfer 2. In a combined analysis of 3 trials (VAST, VIST, and SAMMPRIS), 244 patients were assigned to either vertebral artery stenting or optimal medical The primary end point for this analysis was fatal or nonfatal strokes. Two of these trials (VAST, VIST) contributed data for patients with extracranial vertebral artery stenosis. During 1036 person-years of follow-up, the HR for stenting compared with medical therapy was 0.63 (95% CI, 0.27 1.46). Thus, no clear benefit has been shown for extracranial vertebral artery stenting. 3. No randomized trials have been performed for sur- gical techniques such as vertebral artery endarter- ectomy or transposition. Case series have been reported, but these typically lack a control group with a consistent medical treatment protocol.379 Thus, the utility of these procedures is not well established. Extracranial Large Artery Atherosclerosis Knowledge Gaps and Future Research Knowledge gaps within this area include the following: Risk-benefit ratio of CEA to modern intensive medi- cal therapy should be assessed. Previous CEA trials were initiated >30 years ago, and clinicians need comparisons of CEA with cur- rently available intensive medical therapy options. 