The Avery system can be implanted using a cervical or thoracic approach (VATS, robotic, thoracotomy). The thoracoscopic technique generally requires fewer incisions than other systems, but the approach depends on the patient and surgeon. Implantation is a surgical procedure, typically performed under general anesthesia, lasting 1-3 hours per side. Common approaches include:
             -Cervical (neck): Minimally invasive for patients over 2 years old; ideal for avoiding chest incisions.
             -Thoracoscopic (VATS): Video-assisted through small chest incisions for precise electrode placement on the phrenic nerve. Electrodes are sutured to the phrenic nerves (one or both sides), connected to subcutaneous receivers. Intraoperative testing confirms nerve stimulation. Full pacing usually begins 4-6 weeks post-surgery after healing. Over 2,000 systems have been implanted worldwide in more than 40 countries.

NO: It has been said that it is better to implant the phrenic nerve stimulator close to the diaphragm as in the VATS or the laparoscopic technique.31 It takes an average of 7.5 ms for an impulse applied to the phrenic nerve in the neck to travel the average adult nerve length of 27 cm.32,33 Reducing the time it takes for the applied stimulation to the nerve to induce the diaphragm movement makes no difference to the ability of the diaphragm to pace at the required rate.

ABD provides on-site support for each surgery. The Avery Diaphragm Pacemaker can be implanted via the cervical or thoracic approach, depending on patient needs and surgeon preference. No formal training or specialized tools are required for hospital staff.

On the day of surgery, the ABD representative will assist in testing the equipment in the operating room. The rep will provide hands-on support to the surgical team.

There are Centers of Excellence around the world staffed with experienced pulmonologists and surgeons who specialize in the Avery system. Contact ABD to locate a center or surgeon near you.

Yes, ABD offers both on-site and virtual in-service training for hospital staff leading up to surgery. ABD’s team will work with hospitals to ensure all staff are properly trained, and they will also be physically present in the operating room on the day of surgery to provide hands-on assistance and test the equipment.

NO: Since the early days of PNS there is no evidence that one surgical approach put the nerve at any greater risk than the other approaches. Indeed, since the nerve is stationary at that location during the surgery, there should be less risk to the nerve being surgically injured during cervical implantation. Misconceptions regarding nerve injury via the cervical route of implantation are gradually being corrected as it is understood that this complication was related to a few cases of implantation of an earlier version of the device with a bipolar cuff electrode.14 Nerve injury has not been an issue over the past 38 years with use of the monopolar device since it does not encircle the nerve.

YES: One of the reasons given for using the thoracic over the cervical approach is that the phrenic nerve may not be fully formed above the clavicle making stimulation of the diaphragm less predictable. The phrenic nerve is formed by cervical branches 3, 4 and 5 which reliably unite over the anterior scalene muscle deep to the deep cervical fascia.28 A small accessory branch is occasionally seen joining the main nerve below the clavicle.

RARELY: Cases of ipsilateral shoulder or arm pain or movement have occasionally been observed in some patients using the Avery or Synapse device.33 Shoulder movement with PNS using the cervical approach should be ascertained in the OR at the time of implantation, and if noted, the electrode should be repositioned further from the brachial plexus until this phenomenon is no longer noted. Shoulder pain cannot be assessed intra-operatively unless the monitored anesthesia technique is used. Occasionally, shoulder pain is noted long after implantation; this is thought to be secondary to current leakage through the wire insulation of the electrode and is eliminated with replacement of the wire.

NO: Glenn reported that in his early experience series there was a 2.6% total infection rate resulting in eventual replacement of the system. More infections were encountered using the cervical approach, which was the more common approach during the early experience. The report did not indicate whether the infections originated at the electrode or receiver site. The report did not differentiate between infection incidences associated with the Avery vs the Atrotech electrode/device. Searching the Avery data base for implants after 1985 revealed a 0.13% incidence of infection when implanted cervically vs a 0.25% incidence when implanted thoracically. The lower rate of infection with cervical and thoracic implants is likely due to reduced usage of the bipolar electrode, advances in surgical techniques and surgeons experience with the device.

RARELY: There is virtually no movement in the neck at the site of electrode placement over the anterior scalene muscle. However, electrode wires have been noted to break with repeated arm movement when the electrode wire is tunneled too close to the shoulder using the cervical technique. Wires used in the Synapse and extruding from the abdomen are susceptible to breakage or becoming snagged on external elements as well. In these cases, the affected wires and electrode may need to be replaced.