How to treat arterial ulcers
We have made a list of different treatment modalities for addressing patients with arterial ulcers. We tried to sort the list by prioritizing the most important and putting pain treatment at the top of the list. It is essential for patients who have ischemic pain to address this from the start. Besides that trying to improve the blood circulation by reperfusion techniques performed by invasive radiologists or vascular surgeons is the number one treatment of choice. Under ideal conditions, all patients with an ankle-brachial index (ABI) <0,8 or other apparent signs of ischemic disease should be referred to a vascular center. Unfortunately, this is not a realistic choice for most African patients. In many cases, one may have to resolve by giving advice for exercises the patient can do at home and hoping for the gradual establishment of collateral arteries. Note that the treatment of the wound itself with ointments and dressings is at the very bottom of the list because this, in many ways, is the least important part of the treatment. Health care providers often forget that offloading is much more important than your choice of dressing.
Reperfusion of blocked arteries using either endovascular techniques or bypass surgery
Offloading the ulcer if it is in an area of pressure
Conservative treatment and hoping for sufficient collateral arteries to establish (exercise)
Compression treatment in cases with ischaemic edema ( only in expert hands)
Addressing concomitant diseases such as renal impairment
Make sure the patient is using appropriate shoewear if the ulcers are on the feet
Local treatment of the wound using dressings
Infection control with antibiotics
Management of ischemic pain
We have written a separate chapter on pain treatment where we also address the treatment of ischemic pain so that we do not go into a lengthy discussion here. Instead, we summarize the most important points as take-home messages here:
Ischemic pain is usually quite severe and will interfere with all activities of daily life
The pain is often worse at night when the feet are elevated
If the patient finds it most comfortable to sleep in a reclining chair, let them do this
Ischemic pain is often hard to treat with regular pain medication
Like with other types of pain, it is usual to start with paracetamol as a base
Many patients with peripheral arterial disease ( PAD) also have impaired cardiac and renal function, and non-steroidal antiphlogistics (NSAIDs) are often contraindicated.
If paracetamol is not sufficient ( which it won't be in most cases), try something containing codeine as step two.
If codeine is not sufficient, you will have to try opioids. To decrease the dangers of drug dependency, try to use a long-working opioid supplemented by fast-acting opioids for breakthrough pain. Note, however, that you ( and your patient) will most likely be disappointed about how ineffective opioids are in treating ischemic pain.
In our experience, a combination of Palexia ( a new type of opioid) and Catapresan ( actually an anti-hypertensive medication but which also improves the effect of opioids) has worked relatively well in many cases and has become our medication of choice. We have sometimes even had some success when using Catapresan alone.
Other pain treatments like Neurontin and SSRI (Sarotex) can also be useful analgetic supplements.
Contrary to belief, blood thinning medicine does not improve circulation or diminish ischemic pain! The only exception to this is Trental - a medication with blood-thinning properties that also has an effect in some patients with ischemic pain. It takes a few weeks to see some impact, so this is not the first choice to treat acute pain. In our experience, only about 1/10 of patients have good results with Trental, but it is definitely worth a try since other options often are limited.
Do not attempt compression treatment when the patient has pain- this will only make the pain worse. In any case- compression treatment of patients with PAD and edema must only be carried out in expert hands and followed very closely!
The best treatment for treating ischemic pain is treating the underlying cause- doing something to re-establish the blood supply by endovascular treatment or open surgery!
Note: if the wound is infected, pain levels are usually higher - in other words- treating an infection may also help the patient's pain level.
Figure 1 The treatment of ischemic pain is often complicated and frustrating, and it is an often overlooked part of the treatment of arterial ulcers. If you wish to read more about pain management in wound patients, click on the image above to get to that chapter.
Invasive reperfusion techniques
While this technology is available at some major hospitals in Africa, it is not a realistic option for many patients with ischemic disease on the continent because of limited resources.
To get an arterial ulcer to heal, the blood circulation needs to be improved. The only definite solution to this is to open up the areas of the main arteries, which are narrowed by atherosclerosis. This can often be achieved by minimally invasive techniques where a catheter is introduced into the arteries in the groin and advanced to the narrow areas of the arteries further down the limb. This is called percutaneous transluminal angioplasty (PTA) and is usually performed in local anesthesia by specialist radiologists. The technique usually involves filling up a balloon at the end of the catheter, which "blows up" the narrowed vessels. A stent may be placed at the site to prevent the vessel from contracting again. There have been significant advancements in this field, and some radiologists have managed to treat even small arteries at the foot level.
Depending on where the arteries are narrowed, an open, surgical bypass sometimes needs to be performed. This is usually done in general anesthesia, and a synthetic graft or an autologous donor vessel ( often a vein) is used to bypass the narrowed sections of an artery.
After successful reperfusion by either PTA or bypass surgery, it is normal for the patient to experience temporarily increased edema of the leg, increased redness, and sometimes increased pain. This phase usually lasts for å few weeks. During this time, the ulcer may also have increased secretion, and sometimes the wound even deteriorates before it turns around and starts the healing process. In our experience, it is advisable to wait with any aggressive debridement until this initial postoperative phase with increased edema and inflammation has passed.
It is important to have realistic expectations of what these reperfusion procedures achieve in the long term. Some patients will experience a significant improvement in the limb's circulation, while others may only notice a marginal improvement ( but hopefully enough to get the ulcer to heal). Over time the vessels can narrow again, but if the patients are motivated and exercise regularly, they can build up sufficient collateral arteries to compensate for this.
Note that not all patients are eligible for reperfusion surgery. Age is not necessarily a contraindication, but the patient needs to be able to cooperate ( dementia is a contraindication) and not have contractures, especially in the knee area. In general, if the patient is bedridden without chances for rehabilitation, these surgical procedures are not an option. Patients with advanced atherosclerosis in the limbs almost always have other serious comorbidities like heart- and renal disease, which can be contraindications for the procedure. Most centers also have an absolute no smoking policy - patients who smoke will usually not be offered this treatment.
Figure 2 Above: A modern angiogram lab showing the amount of technical resources needed to perform this procedure
Below: During a percutaneous transluminal angioplasty, a small catheter is introduced into the artery in the groin. Once the catheter has reached the narrow passage of the artery, a balloon is inflated, which reopens the passage. The balloon is then deflated and withdrawn
Non-invasive conservative treatment of arterial circulation
Invasive procedures like PTA and bypass surgery are unfortunately not a realistic option for most patients with peripheral arterial disease in Africa. So what are the alternatives? If there is an onset of gangrene in the foot and with no chance of doing surgical, vascular reconstruction, then the only option is an amputation to save the patient's life!
What about the patients who do not have gangrene but have arterial ulcers? How can we improve their circulation without surgery? To begin with, you have to make sure that all other patient-related factors are optimized. That is, ensuring that the patient has a hemoglobin level of at least > 10g/dl, that blood sugar is stabilized if the patient has diabetes and that nutrition/ fluid intake is optimized. It is essential to ensure extra intake of proteins and vitamins concerning nutrition. Note - eating several spoonfuls of peanut butter per day, for example, can provide an excellent source of additional proteins. Another tip is to encourage the patient to buy baby milk formula and either sprinkle it over a fruit salad daily or mix it with water like you would when preparing formula milk for an infant. This milk powder contains proteins, vitamins, and trace minerals. While baby milk formula is not a substitute for general nutrition for an adult, it can be used as a supplement when other special supplementation products are not available. Both peanut butter and baby milk formula are relatively inexpensive also in Africa. To read more about the nutrition of wound patients, we have written a separate chapter on nutrition.
The patients must stop smoking and other nicotine products immediately.
This was a slight detour from our original question: how can we improve the blood circulation when invasive procedures like PTA and bypass surgery are not available? You have to remember that there is nothing conservative we can do to reopen the arteries already clogged by atherosclerosis. There are no effective medications that can unclog these narrowed vessels. To understand our options, you must realize that the body can form new small blood vessels in areas with low blood circulation - so-called collateral arteries. This is a slow process that takes months to years, and it is definitely not a quick fix.
The key to developing these new collateral arteries is to exercise the muscles of the lower limbs regularly. The good news is that this requires very little of the patient other than that the exercises need to be performed many times a day for this to work. From our own experiences, we often see that the patient may be motivated to do this at the start but that compliance to the training regime gradually drops over time. It is essential to inform the patients that they probably will not feel any improvement for many months and that it is important not to give up too early. Also - make the training program as simple as possible to keep the patient's motivation up. Probably the most effective method for training is supervised exercises ( with a coach), but again, this will not be a realistic option for most areas in Africa where you will have to rely on a home-based exercise program.
The video below is a lecture by Professor Mary McDermott from a University of California Vascular Symposium from 2013 -so not too recent. Still, we like it for the clarity of its message: exercises do make a difference in improving blood circulation. Click on the image to get to the youtube version of the lecture.
Video 1 A lecture by Professor Mary McDermott on the effectiveness of home-based exercises for PAD.
Many videos on youtube show helpful exercises for improving peripheral circulation in the lower limbs. You will have to adapt the training program according to where the patient has the ulcer. If a patient has an ulcer on the plantar side of the heel, we cant encourage walking exercises unless we have ensured good offloading, for example! We will not go into great detail about these exercises- you will find much information on these on other websites. Our main goal here is to encourage you to encourage your patients to do these exercises.
Among the most useful exercises are:
Walking regularly for about 15-20 minutes every day
Doing a cycling movement with the lower limbs. Obviously, this can be done on an actual bicycle, but for most elderly, this is not an option. The patient can imitate cycling by cycling " in the air," but this is difficult to keep up for more than a few minutes. A mini pedal exerciser is ideal for this, and we highly recommend this for all patients with PAD. A welder at most corner workshops in Africa will be able to build this out of an old bicycle.
Walking on toes
The patient should find an exercise routine that they are comfortable with and can do every day. We cannot stress the point too much that you have to inform the patient that it takes at least 12 weeks before they may feel a difference and that they do not give up.
Figure 3 Cycling exercises are beneficial for establishing new collateral arteries. Since most elderly are probably not comfortable on a bicycle, these small pedal exercisers are an excellent alternative for use at home. Again, these will obviously not be readily available to most of your patients. If your patient has the resources, they may get this built by a local welder at little cost using old bicycle parts. However, there must be no sharp edges where the patient can hurt themselves when using such an aid. There should also be a strap around the pedal to ensure that the feet do not slip off the pedal and harm the patient.
If the patient has an ulcer in the ankle area or below, you will always need to make a plan for off-loading the affected area. If the ulcer, for example, is on the lateral malleolus of the ankle, you will have to make sure that no pressure affects the area when the patient is lying on their side. If the ulcers are on the toes or the plantar side of the feet, you will have to find something to reduce the pressure when the patient is walking. We have written a thorough chapter on offloading under " diabetic ulcers" please refer here for more information.
Figure 3 An ischemic diabetic ulcer on the lateral side of the fifth toe due to inadequate shoewear. While the size of the ulcer may not be very impressive, it is nonetheless serious. There is a short distance from the ulcer to the bone, and there is a danger of osteomyelitis developing if we do not handle this correctly. The choice of dressing is of secondary importance here! What is essential is the offloading part. Here we used wool felt pads as offloading. Please refer to our separate chapter on offloading for more information. Note that the red arrow points to another lesion on the dorsum of the third toe. Here we also need to make protective padding. Also - the patient should never again wear the shoes that caused this!
Treating the arterial ulcer itself
Why have we placed the discussion on topical treatment of arterial ulcers at the end of this chapter when this really is what most people want to read about? This is because many health care providers only think about the dressings they use and forget about all the other aspects of peripheral arterial disease that we must address.
In most health care systems in the western world, patients with arterial ulcers are usually referred to a vascular specialist or an advanced wound care clinic. Since this is probably not available to your patients, you will most likely have to deal with these patients on your own. However, discussing your patient with another colleague is always a wise thing to do as arterial ulcers can be challenging to treat.
Dealing with necrosis ( dead tissue)
Necrosis is common in arterial ulcers. A general rule is: if the necrosis is dry - do not touch it! Don't be tempted to do a debridement because it can lead to an even bigger problem. In western health care settings, we generally do not debride dry necrotic tissue until vascular surgical techniques improve blood circulation. If that is not an option, we usually wait and see. If the patient is lucky, there may be enough blood perfusion to slowly heal the wound beneath the dry necrosis. This process takes many months and demands patience. During this time, it is essential to keep the affected part dry. Short showers can be acceptable, but the patient should NOT use footbaths. This could lead to dry necrosis turning into wet necrosis, leading to infection.
The affected part of the foot should be wrapped in something soft and dry - cotton wool on a roll is ideal or soft cotton bandages.
A tip we learned from a practitioner at an older people's home is to saturate the dry necrosis with gentian violet 1% - 1,5% solution about two times per week. The gentian violet solution is slightly absorbed into the necrotic tissue and may act as a prophylactic against infection. We use this routinely and feel that it helps keep the eschar dry, and we seldomly see infections when we use this agent. An article in the Journal of Geriatric Nursing from 2011 ( Farid et al.2011 Gentian Violet 1% Solution in the Treatment of Wounds in the Geriatric Patient: A Retrospective Study) supports this practice. Still, there is little literature to be found on this topic otherwise.
Some caregivers also use 10% povidone-iodine in the same manner, applying it once to twice weekly to the dry necrosis.
Figure 4 1% gentian violet solution is a useful antimicrobial agent to dry out arterial lesions and prevent infection from occurring in dry necrosis. It was a popular, topical treatment in many African countries many years ago and then went somewhat out of fashion. Due to the rise of global antibiotic resistance, we have noted that it is in more demand again. In the chapter on the choice of dressings, we have a more lengthy discussion of the use of gentian violet solution. Some caregivers use 10% povidone iodine for the same purpose. ( copyright Sahara Tribune 2015)
We will now walk you through a few case examples of arterial ulcers and our suggestions for which actions should be taken. All the patients below should be referred to a vascular specialist under ideal conditions. When discussing the patients below, we assume that there are no vascular surgeon resources available.
Figure 3 Dry necrotic tissue at the end of the third toe ( the second toe has been amputated previously). There is a slight inflammation in the toe but no convincing signs of infection. The recommended action here is to keep the necrosis dry and to pad it with whatever you have available for off-loading the area when the patient is using shoes. The shoes should have good space in the toe cap area. Antibiotics are NOT indicated here! There is no need for a special dressing either.
Figure 4 Dry gangrene with thick black eschar. No apparent signs of infection. DO NOT DEBRIDE THIS! Most likely, you will end up with more trouble than you had before the debridement. This is a wait-and-see situation. Obviously, this is a severe situation, and there is a great danger of developing osteomyelitis. You can saturate the black eschar with 1% gentian violet solution to prevent infection from occurring. Antibiotics are NOT indicated here at this stage. The patient cannot use closed shoes - it will be impossible to guarantee that no pressure reaches these areas with necrosis. Advise the patient to use sandals and always use thick socks to cushion the toes. You can pad the necrotic areas in cotton wool, but thick woolen socks may be sufficient as a "dressing" if the necrosis is completely dry.
Figure 5 This patient came to us three months after the onset of the ulcer, which was caused by inappropriate shoewear. We could probe to bone on the top of the necrotic tissue, which indicates possible osteomyelitis. An x-ray confirmed the diagnosis where you can see the destruction of the distal phalanx of the great toe. This needs to be treated with antibiotics. Before giving antibiotics, you should do a bacterial swab of the area where the bone is exposed. The duration of the antibiotic treatment should be 4-6 weeks. From the picture, it may seem that the necrotic tissue was dry, but actually, it was moist necrosis. We would do a very careful serial debridement, using several sessions to remove the necrosis gradually. A regular foam dressing would be our choice here - the foam will provide an adequately moist environment to encourage autolytic debridement and absorb secretions from the wound. The lesson to be learned from this case is to have a low threshold for suspecting osteomyelitis.
Figure 6 This is a severe case, and if the correct measures are not taken immediately, the patient will lose his foot. We see dry gangrene in the second toe, but infection has spread upwards, and there is wet necrosis between both neighboring toes and the dorsum of the foot. There are obvious signs of infection. Note that infection increases the oxygen demand and will rapidly extend the area of tissue damage. This patient needs to be referred to a hospital immediately. The gangrenous toe will have to be amputated and all necrotic tissue debrided under anesthesia. Start the patient on broad-spectrum antibiotics immediately. Total off-loading of the foot is necessary. This sort of case cannot be dealt with in a village dispensary!
Figures 7 & 8 This is a case of ischemic wet gangrene.
A) second toe: If we look closely at the second toe, there are some positive signs like a hint of granulation tissue, at especially the end of the toe, and the deepest ulcer also has some granulation tissue at the edges. There are no apparent signs of infection. However, the main ulcer on the second toe is serious because it lies just above the extensor tendon of the second toe. Once the tendon fibers become exposed, you will most likely not manage to get it to heal.
B) Great toe: Here, we have a large ulcer on the dorsum of the toe. It is impossible to say how deep it is, but it most likely lies in contact with the extensor tendon. Proceed very carefully! You can remove fibrin gently with a q-tip but DO NOT DEBRIDE THIS SHARPLY! You can end up with an exposed tendon which will lead to failure.
Key points: we want to dry out the skin surrounding the main lesions, BUT we do not want to completely dry out the main ulcers as this will have a negative effect on the granulation tissue. This is a good case for using a 1% gentian violet solution on the surrounding skin. In the image on the right, we have drawn in purple where we would have applied the 1% gentian violet solution. Do not use it in the ulcers themselves, although this probably would not be detrimental. Concerning the choice of dressing, our favorite product for these cases would be Sorbact netting as the primary dressing, followed by dry cotton pads. Some people would use foam dressings here, which are also a good choice, preferably with silver content in the first weeks until we have more control over the wound. If you have nothing else than cotton gauze pads, change these often- you want to avoid a wet-dry dressing situation where you end up tearing off viable tissue at each dressing change. Whichever dressing you use, monitor the wounds very closely at the start. The patient cannot use shoes with a closed toe box until the wounds are completely healed.
Figure 9 This case looks more manageable than the cases we reviewed earlier in the chapter. However, don't be fooled by the apparent simplicity of the ulcer - inspect it closely and probe gently to feel for exposed bone. Also here there can be osteomyelitis hiding beneath it. Assuming that this is not the case, this arterial ulcer shows promising signs of granulation tissue, and our job is to promote this tissue from developing more. The key point here is: Do not dry out the granulation tissue - it will die if you do that. A small bit of Polyurethane foam bandage will do all you need here. These foam dressings have absorptive properties but at the same time provide an ideal moisture level in the wound bed, promoting granulation tissue. There are no apparent signs of infection- there is no need for particular anti-bacterial dressings and no indication for antibiotic therapy! The most critical aspect of wound treatment here is off-loading! The patient cannot use shoes with a closed toe box. Instead, we suggest a thick woolen sock over your dressing and a sandal.
Figure 10 A typical arterial ulcer over the lateral malleolus of the left ankle. Note the well-defined edges and the "punched-out" appearance of the ulcer. There is a hard whitish layer in the centre of the wound, which is "yellow necrosis"- necrotic fat and necrotic connective tissue. If you look closely, you see hints of granulation tissue on both the left and right sides of the ulcer. This is a sign that we might get this ulcer to heal.
You can try to debride ever so gently in the centre of the wound - again; we recommend doing serial debridements here to be on the safe side. In other words, only debride a little at each visit to your centre. Keypoints: you do not want to dry out this ulcer! The granulation tissue developing needs an optimal moist environment, AND autolysis will not work if it is too dry in the ulcer. Do not use gentian violet in the wound bed here, as it will probably slow down the autolytic debridement! A polyurethane foam dressing is a good choice for this wound. You may choose to use a foam dressing containing silver for the first couple of weeks, but there is no apparent need for an antimicrobial dressing at this stage. There is slight inflammation around the skin edges which is entirely normal - there is no indication for antibiotics here. Ensure that the edge of the patient's shoe does not come close to the wound area! And again: make a plan for offloading - under no circumstances should there be pressure on the wound when the patient is, for example, lying on the side. Make some sort of padding around the malleolus to prevent this - see also the chapter on offloading. Ulcers over the malleoli of the ankle tend to heal very slowly - one of the reasons is that the ulcer is in an area of unrest- as the ankle moves, the wound bed is disturbed. In some cases, we have used a plaster of Paris cast to immobilise the ankle for a few weeks.
Figure 10 A simplified summary of dressing suggestions for dealing with various arterial ulcers. This shows that your toolbox only needs to contain a few tools to manage these challenging ulcers. The tools in this list are 1% gentian violet solution, cotton gauze pads, Sorbact, polyurethane foam dressings, woolen socks, sandals, and regular polyurethane foam for offloading.
Note that with wounds on the toes, closed shoes should not be used. We advocate the use of thick woolen socks and sandals. Wool breathes well, and if it is thick enough, it will provide some padding. Open shoes carry the risk of some foreign objects coming into the shoe, but there is no real alternative to this. At the bottom of the list, you see a pink foam - similar to mattress foam but thinner and can be used to cushion around arterial pressure ulcers - for example, over the malleoli. The foam is fixated over the primary bandage with tape or a rolled bandage.
If you ask another wound specialist, they may have a different approach to which dressing is best. What we have suggested here is based on our own experiences while we at the same time try to pick products that are more readily available in Africa. Neither Sorbact nor polyurethane dressings may be available in areas of really limited resources. Then you may have to rely solely on cotton gauze pads for all types of arterial ulcers. With a few workarounds, you can do a lot with cotton gauze pads - their main disadvantage is that they can adhere to the wound bed. They may also dry up the wound more than needed and slow down or stop the granulation process. If we only had cotton pads as our only dressing choice, we would add a few drops of honey to the wound bed to ensure that the cotton doesn't dry out the wound too much.
While we are on the topic of honey - what about the use of honey in arterial ulcers? We are definitely advocates for using honey in wound care. And honey will work well in the right type of arterial ulcer. For example, the ulcers in figures 9 and 10 can benefit from the use of honey. We suggest that you start using it sparingly - just a few drops to start with to see how the wound reacts. Remember that honey has a strong osmotic effect which draws water from the wound bed and can lead to maceration and breakdown of the skin edges. So start with a little at a time to prevent this moisture damage to the skin edges and follow the ulcer closely.
We have written a separate chapter on the use of honey in wound care- please refer to that chapter for more information.
Compression treatment in patients with PAD?
As we have described earlier, many patients with peripheral arterial disease (PAD) are quite swollen in the lower extremities. This is called ischemic edema.There are many reasons for this - one factor is that the patients often move little and like to have the feet lowered when resting. This is a detrimental cycle. The edema leads to a localized inflammation and increased oxygen need in the tissue. Edema can increase the pain level also.
Several years ago the use of compression in patients with PAD was seen as a big "No No" by many vascular surgeons. Understandably so because if a compression bandage is too tight in a patient with PAD this can lead to limb threatening complications. This danger is highets in patients with diabetic neuropathy and PAD because these patients may not feel that the bandage is too tight!
So what is the experts opinion on this now? Well, many studies have shown that correctly applied compression may improve the arterial circulation by maybe up to 30%. That sounds paradoxical- how can the arterial flow become better if we tie something around the leg? The explanation for theis is that when the tissue is drained for edema and venous blood the arterial blood easier reaches the capillaries. In theory most patients with ischemic edema will benefit from compression treament. The clue however is that this compression ahs to be applied by someone who is really good with compression bandages and knows its dangers and pitfalls. Also, these patients have to be followed carefully, especially to check that they tolerate compression. Always start carefully with the compression treatment in PAD patients - in the start, it should be so weak that the patient hardly notices it and then gradually increases the level of compression over a couple of weeks. Note: do not use compression if the patient has an AAI of < 0,5!
Arterial ulcers are usually small in size and have little secretion meaning that the use of compression stockings is feasible. We recommend using Class 1 medical grade compression stockings ( the weakest) which are NOT closed in the toes. If the patients tolerates them it is a good idea to wear them at night also. If class 1 stockings are not available then the patient can buy a class 2 stocking which is too big so that it is not too tight. As always with compression - some compression is better than none. The compression has to be so comfortable that the patient is willing to use it. If the patient has the resources to buy a compression garment with velcro this is also a very good alternative - with these garments the patient himself can adjust the level of compression according to comfort levels.
In conclusion: compression treatment for patients with PAD? Absolutely, as long it is done in the right way. Do not attempt to do this unless you have had formal training with compression treatment with PAD patients! We have seen many disasters where some patients ended up being amputated because of too tight compression! Do not use compression if the patient has aa AAI <0,5. If you dont have a means to measure the AAI you actually cannot use compression in the patients!
Giving up nicotine products
It is essential that patients with impaired arterial circulation get help to stop smoking as soon as possible. A few patients realize early that they have to give up their nicotine-use habits. Others need more incentives. Most vascular centers are strict about this and do not offer revascularization procedures as long as the patient smokes.
All use of nictine products causes vasocontriction of blood vessels. Smoking is, however, worse than many other nicotine products, because smoke contains many other chemicals which have a negative impact on circulation and wound healing. It is better to convert a smoker to using nicotine patches or nicotine chewing gum than having them smoking. The best is of course to stop using all nicotine products.
Some patients will not respond to your advice and will keep smoking. We have had patients where a major limb amputation would have been avoidable, had they only stopped smoking a little earlier.