Vascular remodeling in asthma: from mechanisms to precision medicine

Purpose of review: Angiogenesis and lymphangiogenesis are increasingly recognized as dynamic components of airway remodeling in asthma, with potential contributions to airway wall thickening, edema, ventilation-perfusion mismatch and fixed airflow limitation. This review updates mechanistic and translational evidence from the most recent literature and positions vascular biology within precision medicine and disease-modification frameworks. Recent findings: Recent integrative concepts place epithelial barrier dysfunction and alarmin programs upstream of structural disease, providing a biologically plausible bridge between chronic airway injury, innate immune activation and endothelial plasticity across asthma endotypes. Advanced imaging is reshaping phenotyping by enabling non-invasive assessment of structure-function relationships, including airway wall abnormalities and vascular/perfusion signatures relevant to longitudinal monitoring. Long-term data on upstream biologic therapy support sustained clinical benefits over years, strengthening the rationale to test whether vascular abnormalities are modifiable endpoints rather than static consequences of past inflammation. Summary: Vascular remodeling should be considered a clinically meaningful dimension of asthma heterogeneity that may explain persistent impairment despite inflammatory control. Integrating circulating angiogenesis-related mediators with imaging-derived vascular indices could refine risk stratification, inform treatment selection and accelerate a shift from symptom control toward durable disease modification.