As cardiovascular models grow more sophisticated in terms of the geometry considered, and more physiologically realistic boundary conditions are applied, and fluid flow is coupled to structural models, the computational complexity grows. Massively parallel adaptivity and flow solvers with extreme scalability enable cardiovascular simulations to reach an extreme scale while keeping the time-to-solution reasonable. In this paper, we discuss our efforts in this area and provide two demonstrations: one on an extremely large and complex geometry (including many of the major arteries below the neck) where the solution is efficiently captured with anisotropic adaptivity and another case (severe abdominal aorta aneurysm) where the transitional flow leads to extremely large meshes (O(10(9))) and scalability to extremely large core counts (O(10(5))) for both rigid and deforming wall simulations.