Computational fluid dynamics in aortic arch pathologies: current applications, challenges, and future perspectives

The aortic arch is a particularly challenging region in vascular surgery, both as the site of primary pathologies and as a frequent proximal landing zone in extensive thoracoabdominal aortic disease. Its anatomical complexity - defined by curvature, supra-aortic branches, and proximity to the heart - gives rise to intricate hemodynamics characterized by helical secondary flow, vortices, and disturbed wall shear stress. These flow disturbances are implicated in disease progression, thrombus formation, and complications after repair, yet remain incompletely understood. Computational fluid dynamics (CFD) enables quantification of key hemodynamic biomarkers such as wall shear stress, oscillatory shear index, and relative residence time, linking them to outcomes including aneurysm growth, dissection propagation, endoleak, and branch malperfusion. Applications span the treatment spectrum, from preoperative planning and device design to postoperative surveillance and risk stratification. However, routine clinical translation remains limited by reliance on high-quality imaging, complex workflows, and lack of standardization or prospective validation. This review summarizes the current state of CFD in aortic arch pathologies, highlighting advances in modeling strategies, validation approaches, and clinical applications. Finally, we discuss key limitations and future directions, including workflow automation, machine learning integration, and real-time simulation, to support the adoption of CFD as a clinical decision-making tool in precision vascular surgery.