Insights into in-vitro Hemocompatibility

testing according to ISO 10993-4

Hemocompatibility testing of ISO 10993-4:2017 [2] defines the The typical workflow for
blood-contacting medical devices framework for hemocompatibility hemocompatiblity testing is
is one of the most important criteria testing of medical devices to ensure shown in Figure 1. The first
for successful clinical application. an adequate biological and safety step is to set the test design for
Catheters, guide wires, dialyzers, profile prior to clinical application. extraction of the device according
oxygenators, heart-supporting This standard recommends the to the recommendations of ISO
systems, vascular grafts, stents, and testing endpoints that should be 10993-4, ISO 10993-12, and for
heart valves are examples of widely evaluated for different types of clinical use [2],[3]. Determining the
used medical devices coming in medical devices depending on the adequate experimental conditions
direct contact with a patient’s blood. type and duration of blood contact. for hemocompatibility testing of
The recommended endpoint a medical device is a necessary
Blood is a complex “organ” measurements are classified into challenge. In general, test design
composed of 55% plasma, 44% five categories, depending on the strategies should represent the
erythrocytes and 1% leukocytes blood components analyzed: worst-case approach and simulate
and platelets. In plasma, numerous conditions under clinical use [2].
proteins are present that take part 1. Hemolysis: Analysis of the For example, it is important to
in the regulation of the coagulation integrity and damage to red blood determine which parts of the device
and inflammation pathways. The cells. Example: ASTM Hemolysis. may come in direct or indirect
interaction of medical devices contact with circulating blood
with blood leads to cellular and 2. Coagulation: Analysis of during clinical use and for how
humoral reactions, which can the coagulation pathway. long. Another important aspect is to
result in undesired inflammation Examples: Analysis of the Partial determine the blood volume used
and/or coagulation. Thus, these Thromboplastin Time (PTT), for extraction. ISO 10993-12 can
interactions should be carefully Analysis of the Thrombin- provide important guidance in this
analyzed to prevent the adverse Antithrombin complex (TAT). area.
activation or damage of blood
components, in order to minimize 3. Platelets: Analysis of platelet
the risk of harm to patients [1]. loss or activation. Examples:
ß-Thromboglobulin Activity
Using fresh human blood (ß-TG), Platelet Count.
and adequate in-vitro models,
it is possible to analyze the 4. Hematology: Measurement of
hemocompatibility of medical cell depletion and/or leukocyte
devices. In-vitro hemocompatibility activation. Examples: Complete
analysis offers many advantages Blood Count (CBC), Release of
in comparison to in-vivo animal PMN-Elastase.
models. In-vitro models allow for
analysis under well-controlled 5. Complement System: Analysis
conditions, such as blood flow of the complement pathway (part
and anticoagulation, as the blood of the innate immune system).
contact is more intense and Example: Quantification of
products generated due to reaction Sc5b-9.
of the blood components are not
cleared [1].

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For the analysis of a medical in hemocompatibility testing can as well as clinical use and
device, the relevant parts of the help design adequate testing worst case conditions. Thus,
device are incubated with blood, in strategies for a particular type of individual test designs for each
either direct or indirect contact. For medical device based on clinical specific device, together with
direct contact, the medical device use, regulatory requirements, and adequate controls, are essential
is incubated directly with blood. For testing experience. to understanding the interaction
indirect contact, the test device is and compatibility of a device with
extracted using an isotonic solution One particular challenge for human blood and its components.
(NaCl or PBS). Afterwards, the hemocompatibility testing is the
resulting extracts are incubated high donor-to-donor variability
with blood. The extraction can be observed for the blood parameters
performed under static conditions analyzed. This variability makes the
or using a dynamic model, such establishment of specific threshold
as the Chandler Loop or a pump- values or pass/fail criteria difficult.
based recirculating system. Once The lack of defined pass/fail values
the extraction is completed, the in hemocompatibility testing poses
blood is collected and prepared an important challenge for data
for analysis. Testing endpoints evaluation and interpretation.
are then selected from the tests To solve this challenge, Eurofins
recommended in ISO 10993- Medical Device Testing bases a
4:2017 [2], as listed in points one testing strategy on:
through five above.
1. Simultaneous testing and
In summary, the following comparison to validated controls,
aspects should be taken into reporting data as fold-change
consideration when designing a values in comparison to control
hemocompatibility testing strategy:samples.
2. Use of a self-generated database
• Type and duration of blood of positive and negative control
contact. values including multiple donors,
• Surface, weight, and filling which covers for donor-to-donor
capacity of the device. variation.
• Parts of the device with 3. Simultaneous testing of a
direct or indirect blood predicate sample, which defines
contact. the range of values observed in
• Type of material (especially response to marketed, clinically
important for porous safe devices.
materials with high surface
area and volume ratios) Specifically, using a predicate
• Type of blood sample with comparable material
anticoagulant. composition, geometry and clinical
use as the test item provides
• Number of blood donors
a basis for data interpretation
• Static vs. dynamic testing
and discussion [2] and is highly
conditions. recommended by national
authorities like the FDA.
Although ISO 10993-4 provides References:
some guidance on how to perform 1.Weber Marbod, Steinle Heidrun, Golombek Sonia, Hann
In conclusion, hemocompatibility Ludmilla, Schlensak Christian, Wendel Hans P., Avci-Adali
hemocompatibility testing, key Meltem, Blood-Contacting Biomaterials: In Vitro Evaluation
of medical devices can be of the Hemocompatibility, Frontiers in Bioengineering and
steps of the experimental design Biotechnology, 2018
reliably evaluated using the right
such as type of blood anticoagulant, 2.ISO 10993-4: Biological Evaluation of Medical Devices —
combination of different in-vitro Part 4: Selection of tests for interactions with blood. N.p.:
blood volume and duration of blood International Organization for Standardization, 2017
models and an appropriate test
contact remain open. Eurofins 3. ISO 10993-12: Biological evaluation of Medical Devices
design. The test design should - Part 12: Sample preparation and reference materials;
Medical Device Testing’s experts International Organization for Standardization; 2012.
consider regulatory requirements,