Microvascular Effects of Endocannabinoid Signaling in Sepsis: A Mechanistic and Systematic Review

Microvascular dysfunction is a central determinant of organ failure in sepsis, reflecting early endothelial activation, increased permeability, and impaired capillary perfusion. Experimental evidence suggests that the endocannabinoid system (ECS) modulates these immunovascular processes, yet mechanistic insights remain dispersed across heterogeneous models. We conducted a PRISMA-guided systematic review of experimental studies assessing pharmacological modulation of ECS components under sepsis or endotoxemia conditions. Eleven studies met inclusion criteria, encompassing in vivo microcirculatory preparations and in vitro endothelial or immune-cell systems. Across models, three mechanistic domains consistently emerged: leukocyte-endothelial adhesion, endothelial barrier integrity, and vascular reactivity. Among these, cannabinoid receptor 2 (CB2) activation produced the most reproducible effects, reducing adhesion molecule expression and attenuating leukocyte recruitment. Endocannabinoid-endovanilloid signaling contributed to the stabilization of endothelial junctions and limitation of inflammatory hyperpermeability, whereas cannabinoid receptor 1 (CB1) signaling showed context-dependent influences on vascular tone and microvascular flow. These findings outline a coherent framework in which ECS activity-particularly through CB2-shapes early microvascular responses to sepsis. Standardized and clinically relevant models will be essential to determine whether targeting ECS pathways can yield effective strategies to protect the microcirculation during sepsis.