Obesity is associated with insulin resistance, hypertension and cardiovascular disease, but the mechanisms underlying these associations are incompletely understood. Microvascular dysfunction may play an important role in the pathogenesis of both insulin resistance and hypertension in obesity. Adipose tissue-derived substances (adipokines) and especially inflammatory products of adipose tissue control insulin sensitivity and vascular function. Recently, adipose tissue associated with the arterial tree, called perivascular adipose tissue (PAT) has been shown to produce a variety of adipokines and to trigger vascular inflammation. This review summarizes the mechanisms linking adipose tissue to (micro)vascular function, inflammation and insulin resistance with a special focus on the role of PAT in the regulation of vascular tone, endothelial function, inflammation and insulin sensitivity.