Microsurgical techniques increased the operability of patients with critical limb ischemia to more than 95%. However, the percentage of ischemic limb salvage remains limited, especially in diabetic patients with associated tissue gangrene and neuropathy. The study presents a 67 years old female patient with type II diabetes mellitus and critical limb ischemia, complicated with progressive gangrene of the pre-calcaneal region and thus representing a classical indication for thigh amputation. A sequential femur-popliteal-tibial anterior by-pass was performed, followed by soft tissue reconstruction using a latissimus-dorsi musculo-cutaneous free flap. Two years postoperatively, the patient developed clinical signs of symmetrical peripheral distal neuropathy, managed by bilateral posterior tibial nerve decompression. The patient follow-up was of 3 years. Through the entire period, distal pulse (ram of posterior tibial artery) remained present with a good integration of the flap and with absent clinical and paraclinical signs of neuropathy. The patient regained full ambulation. Morphologically and functionally the affected limb is entirely salvaged. Using microsurgical techniques, a more complex and complete approach of the diabetic patient with ischemic-neuropathic syndrome can be considered. This includes revascularization, soft tissue reconstruction and nerve decompression. In selected patients with indication of major amputation these methods offer a salvage option, with excellent long-term results.