ObjectiveWhile current literature reports no advantage for locoregional anesthesia (LRA) over general anesthesia (GA) in patients undergoing carotid endarterectomy (CEA), there remains a gap in understanding the impact of LRA on individuals with congestive heart failure (CHF). This study aims to assess whether the choice of anesthesia influences the rates of perioperative complications within this patient population. MethodsUsing the Vascular Quality Initiative (VQI) carotid endarterectomy module, all patients undergoing CEA between 2013-2023 were identified. The subset of patients with CHF was included, and patients were divided based on the type of anesthesia received. Patient characteristics and outcomes were compared using χ2 or Fischer’s exact test as appropriate for categorical variables and the independent t-test or Mann-Whitney U test as appropriate for continuous variables. A sensitivity analysis was performed based on the symptomatic status of CHF, and the association between anesthesia modality and post-operative outcomes was studied using multivariable logistic regression analysis. The primary outcomes of this study included perioperative stroke, MI, acute heart failure (HF), and the combination of MI and acute HF defined as major cardiac complications. ResultsA total of 21,292 patients (19,730 receiving GA, 1,562 receiving LRA) with a diagnosis of CHF undergoing CEA were identified. On multivariable logistic regression analysis, LRA was independently associated with lower MI (OR 0.35, 95% CI 0.13–0.96), acute HF (OR 0.27, 95% CI 0.09-0.87), major cardiac complications (OR 0.30, 95% CI 0.13-0.67), hemodynamic instability (OR 0.64, 95% CI 0.53-0.78), cranial nerve injury (OR 0.40, 95% CI 0.19-0.81), shunt use (OR 0.25, 95% CI 0.20-0.31), and neuromonitoring device use (OR 0.20, 95% CI 0.17-0.24) compared to GA in symptomatic CHF patients. No difference in MI, acute HF, and major cardiac complications was seen in asymptomatic CHF patients. ConclusionCEA can be safely performed in patients with CHF. Utilizing LRA is associated with a decreased incidence of perioperative cardiac complications in patients with symptomatic heart failure undergoing CEA.