Physiologically, endothelial integrity and smooth muscle homeostasis play key roles in the maintenance of vascular structure and functions. Under pathological conditions, endothelial and smooth muscle cells display great plasticity by transdifferentiating into other cell phenotypes. This review aims to update the progress in endothelial and smooth muscle cell transformation and to discuss their underlying mechanisms. At the early stage of atherosclerosis, it was traditionally believed that smooth muscle cells from the media migrate into the intima in which they proliferate to form neointimal lesions. Recently, endothelial cells were shown to undergo transformation to form smooth muscle-like cells that contribute to neointimal formation. Furthermore, not only can medial smooth muscle cells migrate and proliferate, they also have the ability to differentiate into macrophages in the intima in which they form foam cells by uptaking lipids. Finally, the discovery of stem/progenitor cells in the vessel wall that can differentiate into all types of vascular cells has complicated the research field even further. Based on the current progress in the research field, it is worthy to explore the contributions of cell transformation to the pathogenesis of atherosclerosis to understand the mechanisms on how they are regulated in order to develop novel therapeutic application targeting these processes to reverse the disease progression.