Some experts have suggested that using the side- branch balloon alone will distort the main branch stent and thus this always needs to be a kissing balloon inflation. In patients with low-risk bifurcation lesions (minimal or moderate ostial side-branch disease [ 50% diameter steno- sis] of focal length [5 to 6 mm]), provisional stenting yields similar clinical outcome to elective double stenting, with lower incidence of periprocedural biomarker elevation.726 729 Conversely, in patients with high-risk bifurcations, elective double stenting is associated with a trend toward higher angiographic success rates, lower in-hospital MACE, and better long-term patency of the side branch compared with provisional stenting.193 Culotte, Crush, and T-stent techniques have been studied in RCTs.726 729,737 Use of DES yields better outcomes than BMS,738 and sirolimus-eluting stents yield better outcomes than paclitaxel-eluting stents.739 742 Clinical evidence supports the use of final kissing balloon inflation after elective 5.8.4. Aorto-Ostial Stenoses: Recommendations Class IIa 1. IVUS is reasonable for the assessment of angio- graphically indeterminant left main CAD.744,745 (Level of Evidence: B) 2. Use of DES is reasonable when PCI is indicated in patients with an aorto-ostial stenosis.746,747 (Level of Evidence: B) Aorto-ostial stenoses of native coronary arteries (left main coronary artery and right coronary artery) are most com- monly caused by atherosclerosis, but they can also occur in patients with congenital malformations, radiation exposure, vasculitides, and aortic valve replacement. 