Blood circulation, facilitating gas exchange and nutrient transportation, is a quintessential feature of life in vertebrates. Any disruption to blood flow, may it be by blockade or traumatic rupture, irrevocably leads to tissue infarction or death. Therefore, it is not surprising that hemostasis and vascular adaptation measures have been evolutionarily selected to mitigate the adverse consequences of altered circulation. Blood vessels can be broadly categorized as arteries, veins, or capillaries, based on their structure, hemodynamics, and gas exchange. However, all of them share one property: they are lined with an epithelial sheet called the endothelium, which typically lies on a basement membrane. This endothelium is the primary interface between the flowing blood and the rest of the body, and it has highly specialized molecular mechanisms to detect and respond to changes in blood perfusion. The purpose of this commentary will be to highlight some of the recent developments in the research on blood flow sensing, vascular remodeling, and homeostasis and to discuss the development of innovative pharmaceutical approaches targeting mechanosensing mechanisms to prolong patient survival and improve quality of life. 1. Introduction: physiology of blood flow sensation and adaptation One of the earliest observations of vascular adaptation in response to changes in hemodynamics was made in the nineteenth century by Thoma and these were further investigated by Chapman and Murray in the chick yolk sac; adequate perfusion was found to determine which premature, non-perfused, and unspecified vessels undergo arterial specification and maturation, while under-perfused vessels remain closed and regress [1-3]. These earlier observations are striking: blood vessels are not merely biological pipes, they are dynamic structures shaped by blood flow itself. This dynamic adaptation is not restrained to the developmental stages of the vasculature, with a transient increase in arterial flow being associated with a transient dilation of the mature arteries under increased flow, through vasorelaxant release [4-8]. Furthermore, a sustained increase in flow, as observed in the muscular arteries of physically trained individuals [9,10] or in the uterine artery during pregnancy [11,12], triggers active remodeling of the concerned arteries by increasing their lumen diameter, improving tissue perfusion. Similarly, hypoperfusion of mature blood vessels, following stenosis for example, leads to the inward remodeling of under-perfused vessels. Interestingly, this inward remodeling could not be linked to an increased contraction of the mural cells as vasorelaxants could not relieve it [13]. This indicates a more profound, structural adaptation of the vessel in response to changes in flow. This was later confirmed after observing that mice lacking matrix metalloproteinases could not undergo successful inward remodeling in response to decreased flow due to the lack of remodeling of the collagen matrix [14,15]. These observations, in various animal m...