Over the course of the last three decades the resolution of arterial wall imaging has advanced to the point that it has provided important insights into the factors that drive atherosclerotic disease. In particular, these studies have demonstrated an aggressive form of disease in the diabetic patient. Clinical trials that have employed serial plaque imaging have demonstrated that aggressive modification of metabolic risk factors slows disease progression and in some instances can promote regression of atherosclerotic plaque. The use of arterial wall imaging to evaluate factors underlying disease progression and their role in the clinical management of the diabetic patient will be reviewed.