Vascular diseases (VD), such as cardiovascular diseases, cerebrovascular diseases, and diabetic diseases, originate from numerous pathophysiological changes and remain a serious public health concern. Extracellular vesicles (EVs) produced by cells contribute to regulating VD either dangerously or beneficially. The term EVs refers to the heterogeneous population of vesicles, such as exosomes and microvesicles that participate in cell communication during VD. EVs from different cells, especially those of stem cells, show great promise in the improvement of various VD. They can repair cellular damage, enhance and recover cell function, multiply cells, and prevent cell death and inflammation in specific tissues/cells. EVs have the potential to enhance conditions like cardiovascular disease, cerebrovascular disorders, and complications related to diabetes. Furthermore, an increasing amount of evidence indicates that EVs can be altered/loaded to create a drug delivery system for transporting therapeutic agents to cells, improving different VD. Different methods are used to engineer EVs to improve the efficacy of natural EVs. Despite the potential clinical application of EVs, this field facese many problems that need to be addressed. These limitations and challenges have unmasked the unexpected complexity of EVs regulatory mechanisms, and inspiring advances have been achieved.