The pathogenesis of atherosclerotic cardiovascular disease is complex, involving multiple cell types and biological processes. Extracellular Vesicles (EVs) are small, cell-derived particles increasingly recognized for their role in cardiovascular diseases. EVs are believed to play key roles in this context by promoting inflammation, regulating intercellular communication, and influencing lipid metabolism. As a crucial mediators of cell communication, EVs contribute to both the progression of atherosclerosis (AS) and plaques stability. Although research on the role of EVs in AS and the role of biomarkers or drug carriers in clinical practice has been expanding, several challenges remain for clinical applications, including the lack of specific therapeutic targets for EVs, flaws in the separation and purification processes, and limited clinical trial data on their safety. This review provides a comprehensive overview of the function of EVs in AS and recent advances in their diagnostic and therapeutic potential, aiming to inform future clinical applications.