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Exosomes derived from macrophages, endothelial cells, vascular smooth muscle cells, immune cells, and mesenchymal stem cells participate in several stages of AS progression by transferring bioactive molecules, including microRNAs (miRNAs) and proteins. Macrophage-derived exosomes promote endothelial dysfunction and inflammation, whereas endothelial cell-derived exosomes regulate vascular smooth muscle cell phenotypic switching. Vascular smooth muscle cell-derived exosomes contribute to plaque calcification, while mesenchymal stem cell-derived exosomes appear to exert anti-atherosclerotic effects by suppressing inflammation and promoting M2 macrophage polarization. Exosomal cargos also exhibit potential diagnostic value, with specific expression patterns correlating with disease severity. Furthermore, engineered exosomes have emerged as promising targeted drug delivery systems for AS therapy. 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