Atherosclerosis is a focal chronic inflammatory fibroproliferative disease of the arterial intima caused by the retention of modified low density lipoproteins and hemodynamic stress. Paradoxically, this inflammatory fibroproliferative complex process of repair and healing can become destructive resulting in the remodeling of the arterial vessel wall creating lumen narrowing and ischemia to the involved tissues and organs. In this paper the central role of the endothelial cell is discussed and it is demonstrated how the remodeling within the intima can lead to plaque rupture and thrombosis with arterial occlusion. The role of the injurious stimuli, the response of the endothelial cell, and the adaptive changes within the intima are discussed in relation to arterial vascular remodeling. Intimal vessel wall remodeling and its relation to the development, progression, and final fate of the atherosclerotic plaque cannot be overemphasized.