Consider this situation. A 65-year-old patient admitted to hospital with a troponin-positive acute coronary syndrome (ACS) is initially managed with intensive antithrombotic therapy. Angiography is performed via the femoral artery, demonstrating a tight thrombus-containing lesion in the left anterior descending artery that involves the first diagonal branch. Percutaneous coronary intervention (PCI) is performed, with a stent implanted into the left anterior descending artery, using a kissing balloon procedure to achieve an excellent final result. After this successful and uneventful procedure, the patient is transferred back to the cardiology ward. On arrival at the ward it is noted that the patient has a low blood pressure and complains of groin discomfort. Inspection shows an extensive haematoma at the femoral puncture site. A large and expanding haematoma is demonstrated by ultrasound examination with an associated fall in haemoglobin to 7.2 g/dl. An immediate transfusion of three units of blood is administered and vascular surgical repair is required. Is this a rare, inconvenient, benign and unavoidable component of contemporary ACS management? The MORTAL study, published recently in Heart,1 complements an extensive and rapidly evolving literature that can help to answer these questions.

The prevalence of PCI-related bleeding depends to some extent on the study population and the bleeding definition employed.2 In patients with ACS, the rate of major bleeding is between 3 and 5%.2 3 Femoral access site complications are responsible for most of the bleeding that occurs in invasively managed patients with ACS. The complications of femoral artery access, including hematomas, arteriovenous fistulae, arterial pseudoaneurysms and retroperitoneal haemorrhage, are influenced by anatomical variations, obesity and puncture technique. Glycoprotein IIb/IIIa inhibitors, the use of which are recommended with a class I level of evidence in current ACS guidelines, …