Secondary hyperparathyroidism (SHPT) contributes to mineral-bone disorders, chronic inflammation, and adverse cardiometabolic outcomes in patients undergoing dialysis. Radiomics of epicardial adipose tissue (EAT) derived from computed tomography (CT) may serve as an imaging biomarker of cardiometabolic risk; however, the effect of parathyroidectomy (PTX) on EAT remodeling remains unclear. This cohort study enrolled dialysis patients with severe SHPT who underwent PTX and controls who received standard medical therapy. At baseline and 6 months, the participants underwent CT-based EAT radiomics assessment, coronary artery calcification (CAC) scoring, dual-energy X-ray absorptiometry (DEXA) for body composition and bone mineral density (BMD), and biochemical evaluation. PTX significantly decreased EAT attenuation (-69.99 ± 8.07 to -72.64 ± 5.68 HU; p = 0.04) and increased EAT volume (p = 0.04), indicating a shift toward less inflamed, lipid-rich adipose tissue. Fat mass and BMD increased (p < 0.01), whereas lean mass and resting metabolic rate decreased (p  < 0.01). Controls exhibited stable EAT parameters but showed significant BMD decline (p = 0.02) and CAC progression (p = 0.005). PTX was associated with significantly lower CAC progression according to both the Hokanson and Modified Raggi criteria (p < 0.05). Changes in EAT volume were negatively correlated with changes in attenuation (r = -0.444, p = 0.006). These findings suggest that PTX in dialysis patients with SHPT might modulate cardiometabolic profiles by increasing EAT volume, reducing EAT attenuation, improving bone density, and attenuating CAC progression. Furthermore, CT-derived EAT radiomics may provide complementary biomarkers for cardiometabolic remodeling following PTX. What is knownSecondary hyperparathyroidism (SHPT) in dialysis patients drives mineral–bone disorders, cachexia, and vascular calcification. Epicardial adipose tissue (EAT) radiomics has emerged as a potential imaging biomarker of cardiometabolic risk.This study addsIn dialysis patients with severe SHPT, parathyroidectomy (PTX) increased EAT volume, reduced EAT attenuation, improved bone mineral density (BMD), and attenuated coronary artery calcification (CAC) progression compared with medical therapy. CT-based radiomics revealed a shift toward less inflamed, lipid-rich adipose tissue.Potential impactPTX may mitigate microinflammation and protein-energy wasting, thereby reducing cardiovascular risk in dialysis patients. CT-derived EAT radiomics may provide complementary biomarkers for cardiometabolic remodeling following PTX.