The polarization of macrophages towards an anti-inflammatory and/or pro-tissue repairing phenotype has shown promising potential in the treatment of ischemic diseases. Macrophages play a crucial role in promoting the growth of new blood vessels in ischemic tissue by clearing apoptotic debris caused by hypoxia, recruiting immune cells that support tissue repair, and releasing a variety of cytokines and growth factors. However, there is still a significant knowledge gap regarding the effective induction of this specific macrophage polarization. Non-coding RNAs have demonstrated promise in regulating macrophage activity, although there is a need for more efficient delivery system. Exosomes, which are cell-derived extracellular vesicles ranging from 30 nm to 200 nm in size, have emerged as promising carriers of non-coding RNAs for regulating macrophage activity. This review will discuss the important role of macrophage polarization in ischemic diseases and explore the potential of non-coding RNAs delivered by exosomes in modulating macrophage polarization.