Triple-rule-out computed tomography (CT) angiography revisited: selective contemporary use enabled by sequential acquisition and modern cardiovascular computed tomography (CT).

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Abstract

Triple-rule-out computed tomography angiography (TRO-CTA) was introduced to evaluate acute coronary syndrome (ACS), pulmonary embolism (PE), and acute aortic syndrome (AAS) in a single emergency department (ED) examination. Early single-pass protocols were limited by compromise bolus timing, retrospective gating over a long z-axis, high radiation and iodine burden, and inconsistent coronary image quality, and routine use appropriately declined as dedicated coronary CT angiography (CCTA) and high-sensitivity troponin algorithms matured. A subset of patients nevertheless remains difficult to triage: older or multimorbid patients with overlapping symptoms, nonspecific troponin or D-dimer elevation, or limited access to subspecialty interpretation. Wide-detector and high-pitch acquisition, low-tube-voltage imaging, iterative and deep-learning reconstruction, and artificial intelligence (AI)-based motion correction have reduced the penalties that constrained early protocols, and sequential multiphase acquisition images each territory within its own enhancement window from one coordinated injection. This review reappraises TRO-CTA from a contemporary cardiovascular CT perspective. Dedicated coronary, pulmonary, or aortic CTA remains preferred when one diagnosis is dominant, and selective TRO-CTA is confined to stable patients with persistent diagnostic ambiguity after first-tier evaluation. For contemporary sequential multiphase TRO-CTA, evidence remains largely limited to single-center feasibility and image-quality studies; robust prospective comparative data on diagnostic timeliness, missed diagnoses, downstream testing, and clinical outcomes remain lacking. Value is additionally context-dependent, varying with ED case-mix, scanner platform, availability of expert interpretation, local disease prevalence, and access to staged reassessment. Contemporary TRO-CTA is therefore a selective, institution-calibrated option requiring explicit activation criteria, demonstrated coronary image quality, and prospective multicenter evaluation.

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