Microvascular abnormalities, both in function and structure, lead to impaired tissue perfusion that may affect multiple tissues and organs and seem to be involved in target-organ damage and complications observed in obesity and insulin resistance. In general, vascular remodeling of small arteries associated to cardiometabolic diseases seems to be hypertrophic and it is associated to increased extracellular matrix deposition, although specific vascular beds might show different structural patterns. The mechanisms by which obesity, insulin resistance and/or hyperinsulimemia determine vascular disease are not clear yet but might include hemodynamic factors such as hypertension, activation of the sympathetic nervous and the renin-angiotensin-aldosterone systems, metabolic factors such as insulin and advanced glycation end products and other factors such as adipokines, inflammation or oxidative stress. Exercise and weight loss as well as blockade of the renin-angiotensin system seem to be efficient actions to correct vascular alterations in patients. This review aims to examine the existing literature on structural alterations in small vessels associated to insulin resistance and obesity. A description about the underlying mechanisms possibly responsible of the vascular alterations is also provided. Moreover, effects of pharmacological and non pharmacological strategies that could modify these vascular alterations are summarized.