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Background: The metabolic score for visceral fat (METS-VF) quantifies the cumulative burden of visceral and intra-abdominal adipose tissues. However, the relationship between the METS-VF and carotid atherosclerosis (CAS) has not been extensively explored. Therefore, this study aimed to investigate the association between the METS-VF and CAS. Methods: This cross-sectional study enrolled 7089 Chinese adults who underwent physical examinations at the Zhenhai Lianhua Hospital, Zhejiang, China, in 2020. Multivariable logistic regression analysis was used to explore the linear relationship between METS-VF and CAS. Generalised additive models (GAM) were employed to evaluate potential nonlinear associations. The inflection points of METS-VF were determined using segmented logistic regression analysis optimised for maximum likelihood ratios and recursive algorithms. Results: Multivariable logistic regression analysis revealed a positive correlation between METS-VF and CAS (odds ratio [OR]: 1.824, 95% confidence interval [CI]: 1.753–1.899; P < 0.001). The GAM analysis confirmed a nonlinear association between them [effective degrees of freedom: 4.803, χ2: 876.7, P < 0.001], with an inflection point at a METS-VF of 8.09 (P < 0.001 for log-likelihood ratio test). Below this inflection point, METS-VF exhibited a significant positive association with CAS risk (OR: 1.874, 95% CI: 1.796–1.954; P < 0.001). Conversely, no significant association was observed when METS-VF ≥ 8.09 (OR: 0.998, 95% CI: 0.786–1.268; P = 0.989). Conclusions: METS-VF and CAS demonstrated a positive non-linear correlation, with the curve indicating a saturation effect at METS-VF = 8.09. [ABSTRACT FROM AUTHOR]