Is silver still the Holy Grail for vascular grafts?

Vascular graft infection (VGI) remains one of the most difficult topics within the field of vascular surgery. Despite many preventive measures, infection risk remains present. Mortality and morbidity rates are high, both for peripheral and aortic VGI. Articles reporting on the treatment of VGI are often small, heterogenous or even under reported, which is especially the case for the outcome of different bypass materials that can be used for peripheral VGI. This is one of the reasons why the evidence of which type of vascular graft that should be used in the current guidelines of the European Society of Vascular surgery on the treatment of aortic graft infection is limited to Level C,Class IIa. Nowadays, many types of grafts are being used to treat VGI such as autologous veins, cryopreserved allografts, rifampicin-soaked grafts and silver coated grafts. The antimicrobial effect of silver has been translated to vascular grafts from other disciplines. Nowadays it is commercially off the shelf available and often used in the daily practice, both in the prevention as in the treatment of VGI. The aim of this review was to report on the antimicrobial working mechanism of silver, to report on possible side effects and to summarize in vitro, in vivo and clinical evidence of silver coated vascular grafts, both in the treatment and prevention of VGI.