A 16-year-old boy presents with headache, epistaxis, and leg fatigue on exertion. Examination reveals upper-extremity hypertension (BP 180/95 mmHg in arms vs 110/70 mmHg in legs), diminished femoral pulses with radiofemoral delay, and a continuous murmur over the back. CT angiography reveals the structure marked **A** in the diagram—a focal shelf-like narrowing of the proximal descending aorta just distal to the left subclavian artery at the ligamentum arteriosum. Which of the following best explains the pathophysiology of upper-extremity hypertension in this patient?
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