Exosomes, as crucial mediators of intercellular communication, exhibit a wide range of biological functions in the onset and treatment of atherosclerosis (AS). Recent studies have indicated that exosomes can carry various active substances, including miRNA, lncRNA, proteins, and lipids. By regulating inflammatory responses, lipid metabolism, vascular endothelial function, and the immune microenvironment, they mediate the formation, progression, and reversal of AS at multiple levels. Specifically, miRNAs within exosomes can target and regulate the expression of inflammatory factors, inhibiting macrophage activation and foam cell formation. Meanwhile, exosomes derived from endothelial cells (EC) or stem cells can enhance vascular endothelial integrity and suppress endothelial dysfunction (ED). Furthermore, exosomes have been extensively explored as natural carriers for delivering drugs and nucleic acid molecules. Their membrane structure possesses excellent biocompatibility and targeting capabilities, showcasing significant potential as a novel therapeutic tool. Starting from basic mechanistic studies, this article summarizes the molecular pathways and key biological effects of exosomes in AS intervention, and further explores their current clinical application and multiple challenges they face, aiming to provide theoretical support and research directions for novel cardiovascular disease intervention strategies.