If a patient has discontinued use of the Inspire hypoglossal nerve stimulation system, should the implanted device be removed?

Should the Inspire Device Be Removed if No Longer in Use?

No, the Inspire hypoglossal nerve stimulation device does not need to be routinely removed simply because a patient has discontinued use, unless there are specific clinical indications such as infection, pain, need for MRI incompatibility, poor cosmesis, or planned future procedures that would be complicated by the device.

Clinical Decision Framework

The decision to explant should be based on specific clinical indications rather than non-use alone. Current evidence supports a conservative approach:

Indications for Device Explantation

Based on available case series data, documented reasons for Inspire explantation include 1, 2:

• Infection (most common adverse event requiring explantation at 0.378% within first year) 3
• MRI incompatibility when future imaging is medically necessary 1
• Significant pain or discomfort that cannot be managed conservatively
• Poor cosmesis causing patient distress 1
• Device malfunction requiring replacement rather than revision
• Elective removal (becomes the most common indication by 3 years at 1.478%) 3

Reasons to Leave Device in Place

If the patient is simply not using the device but has no complications:

• Low complication rates: Overall explantation rates are only 0.723% within the first year and 2.680% by 3 years, indicating the device is well-tolerated when left in situ 3
• Surgical complexity: Explantation procedures are technically challenging with mean operative times of 88-163 minutes, and complications are significantly higher when attempting same-session reimplantation (p = 0.018) 4, 1
• Potential for future use: Patients may choose to resume therapy, and the device remains functional if left in place
• Guideline support: Current AASM guidelines emphasize continuation of therapy when feasible but do not mandate removal when discontinued 5

Important Caveats

Surgical planning considerations: If the patient requires future chest wall surgery, cardiac procedures, or frequent MRI imaging, proactive explantation discussion may be warranted 1.

Device monitoring: Even if not actively used, patients should be counseled about the presence of the implant for future medical procedures involving electrocautery or radiofrequency ablation, though recent evidence suggests monopolar electrocautery is safe when used away from the immediate device vicinity 6, 7.

Reimplantation challenges: Should the patient desire future reimplantation with updated technology, extensive scar tissue formation makes this technically difficult with higher complication rates 4.

Practical Approach

The device should remain in place unless:

1. Active infection develops
2. Patient experiences persistent pain or discomfort
3. Future medical needs (MRI, surgery) are incompatible with the device
4. Patient specifically requests removal for cosmetic or psychological reasons

Simply discontinuing use of the device is not an indication for explantation given the low risk of leaving it in place and the surgical complexity of removal.

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