Perivascular adipose tissue (PVAT) directly abuts the lamina adventitia of conduit arteries and actively communicates with the vessel wall to regulate vascular function and inflammation. Mounting evidence suggests that the biological activities of PVAT are governed by perivascular (PV) adipocytes, a unique class of adipocyte with distinct molecular and phenotypic characteristics. Perivascular adipocytes surrounding human coronary arteries (pericoronary PV adipocytes) exhibit a reduced state of adipogenic differentiation and a heightened pro-inflammatory state, secreting up to 50-fold higher levels of the pro-inflammatory cytokine MCP-1 as compared with adipocytes from other regional depots. Thus, PV adipocytes may contribute to upregulated inflammation of PVAT observed in atherosclerotic human blood vessels. On the other hand, PV adipocytes also secrete anti-inflammatory molecules such as adiponectin, and elimination of PVAT in rodent models has been shown to augment vascular disease, suggesting that some amount of PVAT is required to maintain vascular homeostasis. Evidence in animal models and in humans suggests that inflammation of PVAT may be modulated by environmental factors, such as high fat diet and tobacco smoke, which are relevant to atherosclerosis. These findings suggest that the inflammatory phenotype of PVAT is diverse depending on species, anatomic location, and environmental factors, and that these differences are fundamentally important in determining a pathogenic versus protective role of PVAT in vascular disease. Further research into the mechanisms that regulate the inflammatory balance of PV adipocytes may yield new insight into, and treatment strategies for, cardiovascular disease.