Vascular remodeling refers to the alternations of function and structure in vasculature. A complex autocrine/paracrine set of cellular interaction is involved in vascular remodeling. Exosome, a newly identified natural nanocarrier and intercellular messenger, plays a pivotal role in regulating cell-to-cell communication. Exosome emerges as an important mediator in the process of vascular remodeling, showing the most prognostic and therapeutic potent in vascular diseases. Benefiting from exosomal trafficking, the vasculature can not only maintain its function and structure in physiological condition, but also adapt itself in pathological status. In this review, we will represent the roles of exosomes in angiogenesis, endothelial function and cardiac regeneration. In addition, greatly depending on the pathophysiological status of donor cells and peripheral micro-circumstance, the exosomal content could alter, which makes exosomes exhibit pleiotropic effects in vascular diseases. Hence, the diverse effects of exosomes in vascular diseases including atherosclerosis, neointima formation and vascular repair, primary hypertension, pulmonary artery hypertension, and aortic aneurysm will be discussed. Finally, the translational appliances targeting exosomes will be concluded by providing updated applications of engineered exosomes in clinic.